Provider Demographics
NPI:1235513250
Name:KING, MONA LORRAINE (CNP)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:LORRAINE
Last Name:KING
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-672-7422
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4009
Practice Address - Country:US
Practice Address - Phone:612-672-7422
Practice Address - Fax:612-676-8992
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131794/RN 906115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365270301Medicaid
TX539964YKQHMedicare PIN