Provider Demographics
NPI:1568419612
Name:FONG, LAURIE A (APRN,CNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:FONG
Suffix:
Gender:F
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-073941-0364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN109897OtherUCARE MINNESOTA
MN1015289OtherPREFERREDONE
MN444M0FOOtherBLUE SHIELD OF MN
MN62-51179OtherUNITED BEHAVIORAL HEALTH
MN908239500Medicaid
ND71289Medicaid
MNHP19196OtherHEALTHPARTNERS
MN1568419612Medicaid
NDN719254Medicare PIN
MNHP19196OtherHEALTHPARTNERS
MN62-51179OtherUNITED BEHAVIORAL HEALTH
NDN719254Medicare PIN