Basic Information
| Provider Information | |||||||||
| NPI: | 1659858769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOA-AMPONSEM | ||||||||
| FirstName: | MILLICENT | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 RAMSAY ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212233624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1651202730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2018 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 8696 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | R213614 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0808X | R213614 | MD | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.