Basic Information
| Provider Information | |||||||||
| NPI: | 1235513250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | 6126768992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP131794/RN 906115 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 365270301 | 05 | TX | MEDICAID |