Healthcare Provider Details

I. General information

NPI: 1255140745
Provider Name (Legal Business Name): FREDRICK K MOKAYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 SUNFLOWER WAY NORTHWEST
JORDAN MN
55352-5989
US

IV. Provider business mailing address

3112 SUNFLOWER WAY NW
JORDAN MN
55352-6000
US

V. Phone/Fax

Practice location:
  • Phone: 952-686-1816
  • Fax:
Mailing address:
  • Phone: 952-686-1816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2513578
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: