Healthcare Provider Details

I. General information

NPI: 1699793331
Provider Name (Legal Business Name): ANGELA BETH HOMUTH CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3241
  • Fax: 701-237-2573
Mailing address:
  • Phone: 701-232-3241
  • Fax: 701-237-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR25394
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberR25394
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: