Healthcare Provider Details

I. General information

NPI: 1679207013
Provider Name (Legal Business Name): HENRY MOMANYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6773 DEERWOOD LN N
MAPLE GROVE MN
55369-5530
US

IV. Provider business mailing address

6773 DEERWOOD LN N
MAPLE GROVE MN
55369-5530
US

V. Phone/Fax

Practice location:
  • Phone: 612-598-8555
  • Fax:
Mailing address:
  • Phone: 612-598-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9297
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: