Healthcare Provider Details

I. General information

NPI: 1336887827
Provider Name (Legal Business Name): JENNY POTGIETER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 7TH ST NE
DEVILS LAKE ND
58301-2719
US

IV. Provider business mailing address

1031 7TH ST NE
DEVILS LAKE ND
58301-2719
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-2131
  • Fax:
Mailing address:
  • Phone: 701-662-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR32412
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: