Provider Demographics
NPI:1760730980
Name:LEWICKI, KRISTEN EMILY (NP-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:EMILY
Last Name:LEWICKI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:EMILY
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:2027 141ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6551
Mailing Address - Country:US
Mailing Address - Phone:651-338-4027
Mailing Address - Fax:
Practice Address - Street 1:10705 TOWN SQUARE DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8184
Practice Address - Country:US
Practice Address - Phone:763-236-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF0712464363LF0000X
MN3273363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily