Provider Demographics
NPI:1801240205
Name:MAMBO, ERNESTINE
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:
Last Name:MAMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 BITTERSWEET ST NW
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1210
Mailing Address - Country:US
Mailing Address - Phone:651-408-5286
Mailing Address - Fax:
Practice Address - Street 1:3301 7TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-4516
Practice Address - Country:US
Practice Address - Phone:651-431-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4350363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily