Healthcare Provider Details

I. General information

NPI: 1811787666
Provider Name (Legal Business Name): TIMOTHY TITA ETONDE DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S COLUMBIA RD
GRAND FORKS ND
58201-4028
US

IV. Provider business mailing address

PO BOX 860939
MINNEAPOLIS MN
55486-0939
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202345
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: