Provider Demographics
NPI:1104870906
Name:MAUDER, MICHELLE (RN,CNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MAUDER
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 1:360 COLBORNE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3228
Mailing Address - Country:US
Mailing Address - Phone:651-767-8380
Mailing Address - Fax:651-228-3649
Practice Address - Street 1:360 COLBORNE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-3228
Practice Address - Country:US
Practice Address - Phone:651-767-8189
Practice Address - Fax:651-228-3649
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR143864-2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN246910300Medicaid