Provider Demographics
NPI:1306221460
Name:FONDONG, MULUH F (NP)
Entity Type:Individual
Prefix:
First Name:MULUH
Middle Name:F
Last Name:FONDONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 SNELLING AVE N STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5585
Mailing Address - Country:US
Mailing Address - Phone:651-363-3111
Mailing Address - Fax:888-975-0905
Practice Address - Street 1:1618 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1335
Practice Address - Country:US
Practice Address - Phone:218-207-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR219786-9363LF0000X
MN4015363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400241078Medicare UPIN
MNH400241076Medicare UPIN