=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073325619
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY SWEETIE DUNDAS MONGRUE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2025
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 SHINGLE CREEK PKWY STE 250Q
-----------------------------------------------------
City | BROOKLYN CENTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55430-2382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-898-9308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 353 JAY WAY
-----------------------------------------------------
City | VADNAIS HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55127-7953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-900-0861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | A472490500
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------