=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578497467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONSTANTINE NADIA ASANGWE TIMBONG PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2026
-----------------------------------------------------
Last Update Date | 06/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3815 W BROADWAY AVE
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-656-0361
-----------------------------------------------------
Fax | 763-588-7061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17207 55TH ST NE
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55374-4598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-957-0647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 13860
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------