Healthcare Provider Details

I. General information

NPI: 1598413312
Provider Name (Legal Business Name): MICHELLE JILL REXINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 37TH AVE S # 1
FARGO ND
58104-3400
US

IV. Provider business mailing address

PO BOX 13238
GRAND FORKS ND
58208-3238
US

V. Phone/Fax

Practice location:
  • Phone: 701-516-4637
  • Fax:
Mailing address:
  • Phone: 701-516-4637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR31653
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR31653
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: