Healthcare Provider Details

I. General information

NPI: 1114720703
Provider Name (Legal Business Name): FAITH NYAENYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

8502 ROSEWOOD CT
MAPLE GROVE MN
55369-9139
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-6062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12333
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: