Provider Demographics
NPI:1447667456
Name:MIETUS, STACEY THOMPSON (APRN, CNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:THOMPSON
Last Name:MIETUS
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 42ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1615
Mailing Address - Country:US
Mailing Address - Phone:612-226-2912
Mailing Address - Fax:612-474-9072
Practice Address - Street 1:428 MINNESOTA ST STE 500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2666
Practice Address - Country:US
Practice Address - Phone:612-662-9604
Practice Address - Fax:612-474-9072
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2470293163W00000X
MN6409363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse