Provider Demographics
NPI:1659858769
Name:BOA-AMPONSEM, MILLICENT (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:
Last Name:BOA-AMPONSEM
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 1:2215 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-4385
Mailing Address - Country:US
Mailing Address - Phone:612-596-9438
Mailing Address - Fax:612-329-4500
Practice Address - Street 1:2215 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-4385
Practice Address - Country:US
Practice Address - Phone:612-596-9438
Practice Address - Fax:612-329-4500
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR213614163WP0808X, 363LP0808X
MN8696363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health