Provider Demographics
NPI:1467114249
Name:UKPONG, INIOBONG NNAMDIE
Entity Type:Individual
Prefix:
First Name:INIOBONG
Middle Name:NNAMDIE
Last Name:UKPONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6066 59TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5729
Mailing Address - Country:US
Mailing Address - Phone:832-351-0062
Mailing Address - Fax:
Practice Address - Street 1:6066 59TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5729
Practice Address - Country:US
Practice Address - Phone:832-351-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily