Healthcare Provider Details

I. General information

NPI: 1558287763
Provider Name (Legal Business Name): KRISTI ANN SHAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-3450
  • Fax: 701-364-3382
Mailing address:
  • Phone: 701-364-3450
  • Fax: 701-364-3382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number54031
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: