Provider Demographics
NPI:1659858769
Name:BOA-AMPONSEM, MILLICENT (DNP, PMHNP-BC, CRNP)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:
Last Name:BOA-AMPONSEM
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:14800 GALAXIE AVE STE 305
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4530
Practice Address - Country:US
Practice Address - Phone:952-432-1484
Practice Address - Fax:952-432-2328
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1971170163W00000X
MDR213614163WP0808X, 363LP0808X
MN8696363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health