Basic Information
| Provider Information | |||||||||
| NPI: | 1568419612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | APRN,CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | R-073941-0 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 363LP0808X | R-073941-0 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 109897 | 01 | MN | UCARE MINNESOTA | OTHER | 1015289 | 01 | MN | PREFERREDONE | OTHER | 444M0FO | 01 | MN | BLUE SHIELD OF MN | OTHER | 62-51179 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER | 908239500 | 05 | MN | MEDICAID | 71289 | 05 | ND | MEDICAID | HP19196 | 01 | MN | HEALTHPARTNERS | OTHER | 1568419612 | 05 | MN | MEDICAID |