Healthcare Provider Details

I. General information

NPI: 1013825421
Provider Name (Legal Business Name): STACIE JOY MONGOLD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

00 WASHINGTON AVE S SUITE 1210
MINNEAPOLIS MN
55401
US

IV. Provider business mailing address

28515 N NORTH VALLEY PKWY APT 1049
PHOENIX AZ
85085-5430
US

V. Phone/Fax

Practice location:
  • Phone: 866-492-5336
  • Fax:
Mailing address:
  • Phone: 757-636-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF08260708
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: