Healthcare Provider Details

I. General information

NPI: 1790599264
Provider Name (Legal Business Name): ELIZABETH KATHRYN WAYNE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

1505 55TH AVE S
FARGO ND
58104-6397
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax: 701-451-7827
Mailing address:
  • Phone: 701-212-5947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR41708
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: