Provider Demographics
NPI:1275190027
Name:GEHYIGON-WALLACE, PRINCESS
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:
Last Name:GEHYIGON-WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PRINCESS
Other - Middle Name:
Other - Last Name:GEHYIGON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7362 UNIVERSITY AVE NE # 310-3
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3142
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:7362 UNIVERSITY AVE NE STE 310-3
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:612-567-9587
Practice Address - Fax:763-201-3093
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6598363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health