MEDICARE: MS. CAROL SUE MOEN NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	R20055	ND

General Provider Information

NPI Number	:	1619939006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL SUE MOEN NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	5312 118TH AVE NE
Second Line	:
City	:	MICHIGAN
State	:	ND
Zip	:	58259-9452
Country	:	US
Telephone Number	:	701-259-2339
Fax Number	:

Provider Business Practice Location Address
First Line	:	524 4TH AVE NE
Second Line	:	UNIT 9
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-2490
Country	:	US
Telephone Number	:	701-662-7046
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	07/08/2007

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