Healthcare Provider Details

I. General information

NPI: 1730905852
Provider Name (Legal Business Name): AMANDA KATHLEEN LEE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

1215 4TH ST NW
WEST FARGO ND
58078-3935
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3770
  • Fax:
Mailing address:
  • Phone: 701-367-3865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR42925
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: