Healthcare Provider Details

I. General information

NPI: 1710704580
Provider Name (Legal Business Name): DIAN SUDENE GRAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 BELSLY BLVD
MOORHEAD MN
56560-5057
US

IV. Provider business mailing address

803 BELSLY BLVD
MOORHEAD MN
56560-5057
US

V. Phone/Fax

Practice location:
  • Phone: 218-236-7145
  • Fax:
Mailing address:
  • Phone: 218-236-7145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13709
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: