Provider Demographics
NPI:1740269927
Name:MIKE, DEBRA KAY (RN, CNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:KAY
Last Name:MIKE
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7880 DAWN AVE
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-3136
Mailing Address - Country:US
Mailing Address - Phone:651-450-5598
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH STREET
Practice Address - Street 2:SUITE 290
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-914-1727
Practice Address - Fax:952-914-1727
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD149363-21363LA2200X
MD146979-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0373257-00Medicaid
MNR94988Medicare UPIN
MN0373257-00Medicaid