Individual
MAI TIA LY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
REGISTERED NURSE
Contact information
Practice address
2499 RICE ST, SUITE 132, ROSEVILLE, MN 55113-3724
(651) 494-9058
(651) 494-6680
Mailing address
2499 RICE ST, SUITE 132, ROSEVILLE, MN 55113-3724
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
R194859-8
MN
Other
Enumeration date
03/15/2011
Last updated
04/02/2019
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