Provider Demographics
NPI:1265731319
Name:LY, MAI TIA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:TIA
Last Name:LY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 RICE ST
Mailing Address - Street 2:SUITE 132
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2499 RICE ST
Practice Address - Street 2:SUITE 132
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3724
Practice Address - Country:US
Practice Address - Phone:651-494-9058
Practice Address - Fax:651-494-6680
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR194859-8163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse