Healthcare Provider Details

I. General information

NPI: 1679129555
Provider Name (Legal Business Name): ASHLEY MARIE WAVRIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 10/16/2021
Certification Date: 10/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax: 218-333-5360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6825
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: