Provider Demographics
NPI:1407662265
Name:MOU-BAYONG, NCHE (BSN,PHN)
Entity type:Individual
Prefix:
First Name:NCHE
Middle Name:
Last Name:MOU-BAYONG
Suffix:
Gender:M
Credentials:BSN,PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4373 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-7585
Mailing Address - Country:US
Mailing Address - Phone:651-354-2819
Mailing Address - Fax:
Practice Address - Street 1:1558 E 80TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1158
Practice Address - Country:US
Practice Address - Phone:651-354-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2342135163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty