Provider Demographics
NPI:1396387593
Name:MOSTROM, ANGELA (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MOSTROM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14460 CASTLEGATE WAY NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-4001
Mailing Address - Country:US
Mailing Address - Phone:952-457-0407
Mailing Address - Fax:
Practice Address - Street 1:1451 ADAMS ST S
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2697
Practice Address - Country:US
Practice Address - Phone:952-428-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6980363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner