Healthcare Provider Details

I. General information

NPI: 1013725340
Provider Name (Legal Business Name): PERSONAL NUTRITION & WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 31ST AVE S
FARGO ND
58104-4556
US

IV. Provider business mailing address

4450 31ST AVE S
FARGO ND
58104-4556
US

V. Phone/Fax

Practice location:
  • Phone: 763-300-4816
  • Fax: 763-299-1002
Mailing address:
  • Phone: 763-300-4816
  • Fax: 763-299-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY FLATEN
Title or Position: CEO/PRESIDENT
Credential: CNS, LN
Phone: 763-300-4816