Healthcare Provider Details

I. General information

NPI: 1275190027
Provider Name (Legal Business Name): PRINCESS GEHYIGON-WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRINCESS GEHYIGON

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7362 UNIVERSITY AVE NE STE 310-3
FRIDLEY MN
55432-3142
US

IV. Provider business mailing address

7362 UNIVERSITY AVE NE # 310-3
FRIDLEY MN
55432-3142
US

V. Phone/Fax

Practice location:
  • Phone: 612-567-9587
  • Fax: 763-201-3093
Mailing address:
  • Phone: 651-628-9566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6598
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: