Provider Demographics
NPI:1609205707
Name:SISAY, MAHILET (CNP)
Entity Type:Individual
Prefix:
First Name:MAHILET
Middle Name:
Last Name:SISAY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 DAVERN ST APT 408
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2290
Mailing Address - Country:US
Mailing Address - Phone:651-925-9735
Mailing Address - Fax:
Practice Address - Street 1:5320 W 23RD ST STE 130
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1670
Practice Address - Country:US
Practice Address - Phone:952-345-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10934363LG0600X
MNR 203829-0163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)