Healthcare Provider Details

I. General information

NPI: 1689636615
Provider Name (Legal Business Name): STACEY M EHLERS-MILLETT R.N., C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 PHALEN BLVD
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-8680
  • Fax: 651-254-8656
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3329
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR123301-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: