Healthcare Provider Details

I. General information

NPI: 1861321028
Provider Name (Legal Business Name): MISS ALEXANDRA JO MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEX MCDONOUGH

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date: 05/14/2026
Reactivation Date: 07/28/2026

III. Provider practice location address

11660 ROUND LAKE BLVD NW
COON RAPIDS MN
55433-2638
US

IV. Provider business mailing address

11660 ROUND LAKE BLVD NW
COON RAPIDS MN
55433-2638
US

V. Phone/Fax

Practice location:
  • Phone: 763-767-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: