Healthcare Provider Details

I. General information

NPI: 1568286136
Provider Name (Legal Business Name): EDIE MARIE MEAGHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

4704 10TH AVE S
FARGO ND
58103-7238
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3241
  • Fax:
Mailing address:
  • Phone: 701-213-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR24174
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: