=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588312458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAOMI B MACHUNGO DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 DOUGLAS DR N
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-400-3628
-----------------------------------------------------
Fax | 763-342-4183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2004 FORD PKWY
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-256-8225
-----------------------------------------------------
Fax | 612-457-0216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 8524
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------