Healthcare Provider Details

I. General information

NPI: 1366650277
Provider Name (Legal Business Name): MARY L SPRAGUE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NP AVE N
FARGO ND
58102-4835
US

IV. Provider business mailing address

301 NP AVE N
FARGO ND
58102-4835
US

V. Phone/Fax

Practice location:
  • Phone: 701-271-3344
  • Fax:
Mailing address:
  • Phone: 701-271-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License NumberR25777
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR25777
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: