Provider Demographics
NPI:1164602363
Name:INGUTIA, MIRIAM (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:INGUTIA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 79TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2655
Mailing Address - Country:US
Mailing Address - Phone:763-424-5631
Mailing Address - Fax:
Practice Address - Street 1:3301 7TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-4516
Practice Address - Country:US
Practice Address - Phone:651-431-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-146675-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily