Healthcare Provider Details

I. General information

NPI: 1093029076
Provider Name (Legal Business Name): MIRANDA DAWN STANLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 TYLER PKWY SUITE 4
BISMARCK ND
58503-0871
US

IV. Provider business mailing address

2331 TYLER PKWY SUITE 4
BISMARCK ND
58503-0871
US

V. Phone/Fax

Practice location:
  • Phone: 701-255-4000
  • Fax: 701-255-1992
Mailing address:
  • Phone: 701-255-4000
  • Fax: 701-255-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR29452
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: