Healthcare Provider Details

I. General information

NPI: 1598590556
Provider Name (Legal Business Name): DESIRE B NKINZINGABO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4272 31ST AVE S
FARGO ND
58104-8725
US

IV. Provider business mailing address

4272 31ST AVE S
FARGO ND
58104-8725
US

V. Phone/Fax

Practice location:
  • Phone: 701-200-3783
  • Fax:
Mailing address:
  • Phone: 701-200-3783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberDEDEB
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: