Healthcare Provider Details

I. General information

NPI: 1740667260
Provider Name (Legal Business Name): JENEIL GREEK RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S ROUTE 2500
FARGO ND
58103-5800
US

IV. Provider business mailing address

2400 32ND AVE S ROUTE 2500
FARGO ND
58103-5800
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8648
  • Fax: 701-234-8717
Mailing address:
  • Phone: 701-234-8648
  • Fax: 701-234-8717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number223412-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR33903
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: