Healthcare Provider Details

I. General information

NPI: 1053555797
Provider Name (Legal Business Name): MS. MAIJA L DUPPONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 2ND ST NE
FOSSTON MN
56542-1301
US

IV. Provider business mailing address

900 HILLIGOSS BLVD SE
FOSSTON MN
56542-1542
US

V. Phone/Fax

Practice location:
  • Phone: 218-435-1111
  • Fax: 218-435-1112
Mailing address:
  • Phone: 218-435-1133
  • Fax: 218-435-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 188975-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: