Healthcare Provider Details

I. General information

NPI: 1679423081
Provider Name (Legal Business Name): HEATHER RAE MIKKELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 9TH AVE S STE D
FARGO ND
58103-2101
US

IV. Provider business mailing address

4025 9TH AVE S STE D
FARGO ND
58103-2101
US

V. Phone/Fax

Practice location:
  • Phone: 701-551-2446
  • Fax: 701-364-9938
Mailing address:
  • Phone: 701-551-2446
  • Fax: 701-364-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTECH581
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: