Provider Demographics
NPI:1811768088
Name:FONCHAM, NEH BUMA (PSYCHIATRIC NP)
Entity type:Individual
Prefix:
First Name:NEH
Middle Name:BUMA
Last Name:FONCHAM
Suffix:
Gender:F
Credentials:PSYCHIATRIC NP
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:160 KELLOGG BLVD
Mailing Address - Street 2:7800
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101
Mailing Address - Country:US
Mailing Address - Phone:651-341-4260
Mailing Address - Fax:
Practice Address - Street 1:20416 EVERTON TRL N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8161
Practice Address - Country:US
Practice Address - Phone:651-470-3265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN11062363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health