Individual
NEH BUMA FONCHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSYCHIATRIC NP
Contact information
Practice address
20416 EVERTON TRL N, FOREST LAKE, MN 55025-8161
(651) 470-3265
Mailing address
160 KELLOGG BLVD, 7800, ST PAUL, MN 55101
(651) 341-4260
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
11062
MN
Other
Enumeration date
01/15/2024
Last updated
01/15/2024
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