Provider Demographics
NPI:1194593566
Name:MAPLE PSYCHIATRY
Entity type:Organization
Organization Name:MAPLE PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKETTE IKEBATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:425-446-0012
Mailing Address - Street 1:202 N CEDAR AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2306
Mailing Address - Country:US
Mailing Address - Phone:425-446-0012
Mailing Address - Fax:
Practice Address - Street 1:1873 SHRYER AVE W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5413
Practice Address - Country:US
Practice Address - Phone:425-446-0012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty