Healthcare Provider Details

I. General information

NPI: 1124981071
Provider Name (Legal Business Name): MICHELLE STACHOWSKI LSN,RN,PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 12TH AVE S
MOORHEAD MN
56560-8100
US

IV. Provider business mailing address

3601 12TH AVE S
MOORHEAD MN
56560-8100
US

V. Phone/Fax

Practice location:
  • Phone: 218-284-8311
  • Fax: 218-284-6533
Mailing address:
  • Phone: 218-284-8311
  • Fax: 218-284-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number23078995
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: