Healthcare Provider Details

I. General information

NPI: 1003059478
Provider Name (Legal Business Name): MAVIS OSEI YEBOAH NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

IV. Provider business mailing address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

V. Phone/Fax

Practice location:
  • Phone: 336-549-6221
  • Fax:
Mailing address:
  • Phone: 855-247-8474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5004181
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: