Provider Demographics
NPI:1669979449
Name:ONYENEHO, KIESHA M (MD)
Entity type:Individual
Prefix:
First Name:KIESHA
Middle Name:M
Last Name:ONYENEHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIESHA
Other - Middle Name:
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-736-4180
Mailing Address - Fax:
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4334
Practice Address - Country:US
Practice Address - Phone:701-683-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69236207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program