Healthcare Provider Details

I. General information

NPI: 1063404168
Provider Name (Legal Business Name): ELIZABETH J SIQVELAND CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 SMITH AVE N CHILDRENS SPECIALTY CLINIC-GENETICS-STPL
SAINT PAUL MN
55102-2387
US

IV. Provider business mailing address

2910 CENTRE POINTE DR 35-121A, CHILDRENS HEALTH CARE
ROSEVILLE MN
55113-1182
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6884
  • Fax: 651-220-6248
Mailing address:
  • Phone: 651-855-2327
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR1386079
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: