Provider Demographics
NPI:1790443075
Name:AKO-EBOT, KERENGE AYUK
Entity Type:Individual
Prefix:
First Name:KERENGE
Middle Name:AYUK
Last Name:AKO-EBOT
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 1:1675 HIGHWAY 96 E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3617
Mailing Address - Country:US
Mailing Address - Phone:651-442-6406
Mailing Address - Fax:
Practice Address - Street 1:1675 HIGHWAY 96 E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3617
Practice Address - Country:US
Practice Address - Phone:651-442-6406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8588363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty