Healthcare Provider Details

I. General information

NPI: 1629401708
Provider Name (Legal Business Name): LISA MARIE NORDQUIST DVM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 GRAND AVE
DULUTH MN
55807-2537
US

IV. Provider business mailing address

5502 GRAND AVE
DULUTH MN
55807-2538
US

V. Phone/Fax

Practice location:
  • Phone: 218-628-0301
  • Fax: 218-628-1448
Mailing address:
  • Phone: 218-628-0301
  • Fax: 218-628-1448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number09108
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: