Healthcare Provider Details

I. General information

NPI: 1568419612
Provider Name (Legal Business Name): LAURIE A. FONG APRN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

IV. Provider business mailing address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-5611
  • Fax: 218-847-0881
Mailing address:
  • Phone: 218-847-5611
  • Fax: 218-847-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR-073941-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR-073941-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: