Provider Demographics
NPI:1336775782
Name:MANDIEKA, SURVIVAL DAMARIS (DNP, APRN,CNP)
Entity Type:Individual
Prefix:DR
First Name:SURVIVAL
Middle Name:DAMARIS
Last Name:MANDIEKA
Suffix:
Gender:F
Credentials:DNP, APRN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2900
Mailing Address - Country:US
Mailing Address - Phone:612-298-8044
Mailing Address - Fax:
Practice Address - Street 1:1816 GRANITE DR
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2900
Practice Address - Country:US
Practice Address - Phone:612-298-8044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0000000000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily