Provider Demographics
NPI:1730164567
Name:LIETZAU, KATHLEEN J (APCNS)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:J
Last Name:LIETZAU
Suffix:
Gender:F
Credentials:APCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:
Practice Address - Street 1:6950 146TH ST W
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4513
Practice Address - Country:US
Practice Address - Phone:952-432-1484
Practice Address - Fax:952-432-2328
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR94581-9163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN392143300Medicaid