Provider Demographics
NPI:1679348247
Name:TONA, ANTENALU DESTA
Entity type:Individual
Prefix:
First Name:ANTENALU
Middle Name:DESTA
Last Name:TONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1135
Mailing Address - Country:US
Mailing Address - Phone:612-886-5439
Mailing Address - Fax:
Practice Address - Street 1:8340 5TH ST NE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-1135
Practice Address - Country:US
Practice Address - Phone:612-886-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-23
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10993363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health