Provider Demographics
NPI:1417169301
Name:MOUA, MAILY
Entity Type:Individual
Prefix:
First Name:MAILY
Middle Name:
Last Name:MOUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 MOGAN AVNUE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411
Mailing Address - Country:US
Mailing Address - Phone:612-588-9226
Mailing Address - Fax:
Practice Address - Street 1:2826 MOGAN AVNUE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411
Practice Address - Country:US
Practice Address - Phone:612-588-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant