Provider Demographics
NPI:1053110072
Name:MOUGEY, KRISTA MARIE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:MOUGEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 MAIN AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1956
Mailing Address - Country:US
Mailing Address - Phone:701-289-7676
Mailing Address - Fax:
Practice Address - Street 1:417 MAIN AVE STE 401
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1956
Practice Address - Country:US
Practice Address - Phone:701-289-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND643175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist