Healthcare Provider Details

I. General information

NPI: 1164256087
Provider Name (Legal Business Name): CHRIS MOKONGU PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

V. Phone/Fax

Practice location:
  • Phone: 612-725-2000
  • Fax:
Mailing address:
  • Phone: 612-725-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11924
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: