Provider Demographics
NPI:1639950348
Name:MOZINGO, MAILYN MARIE (PMHNP)
Entity type:Individual
Prefix:
First Name:MAILYN
Middle Name:MARIE
Last Name:MOZINGO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 LIONHEART DRIVE
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047
Mailing Address - Country:US
Mailing Address - Phone:701-204-2804
Mailing Address - Fax:
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1914
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR40973363LP0808X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry