Healthcare Provider Details

I. General information

NPI: 1467201301
Provider Name (Legal Business Name): EDGE HEALTH CARE AND MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 GRASS LAKE PL APT 309
SHOREVIEW MN
55126-2063
US

IV. Provider business mailing address

157 GRASS LAKE PL APT 309
SHOREVIEW MN
55126-2063
US

V. Phone/Fax

Practice location:
  • Phone: 763-498-4448
  • Fax:
Mailing address:
  • Phone: 763-498-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EKAN EKONG
Title or Position: PMHNP-BC
Credential: NP
Phone: 763-498-4448