Healthcare Provider Details

I. General information

NPI: 1669979449
Provider Name (Legal Business Name): KIESHA M. ONYENEHO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIESHA BULLOCK MD

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 MAIN ST
LISBON ND
58054-4334
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-683-6400
  • Fax:
Mailing address:
  • Phone: 701-736-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69236
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: