Provider Demographics
NPI:1750034633
Name:KMIECIAK, MOLLY SUE (LPN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:SUE
Last Name:KMIECIAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E MEDICINE LAKE BLVD OFC 114
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2307
Mailing Address - Country:US
Mailing Address - Phone:763-231-5939
Mailing Address - Fax:
Practice Address - Street 1:5981 MAIN ST NE UPPR APT
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5442
Practice Address - Country:US
Practice Address - Phone:612-707-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN774349164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse