Provider Demographics
NPI:1770876187
Name:KOIVISTO, DUANE OLIVER (LPN)
Entity type:Individual
Prefix:MR
First Name:DUANE
Middle Name:OLIVER
Last Name:KOIVISTO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 1ST AVE S
Mailing Address - Street 2:#104
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4368
Mailing Address - Country:US
Mailing Address - Phone:612-825-2905
Mailing Address - Fax:
Practice Address - Street 1:11400 JULIANNE AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9436
Practice Address - Country:US
Practice Address - Phone:651-426-3300
Practice Address - Fax:651-426-0419
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 63350-3164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse