Provider Demographics
NPI:1710592530
Name:KIAWOIN, MILDRED DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:DENISE
Last Name:KIAWOIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 CENTRAL PARK WAY
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2651
Mailing Address - Country:US
Mailing Address - Phone:763-807-5334
Mailing Address - Fax:
Practice Address - Street 1:777 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1522
Practice Address - Country:US
Practice Address - Phone:651-447-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8864363L00000X
MN2149914163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner