Healthcare Provider Details

I. General information

NPI: 1346920576
Provider Name (Legal Business Name): KATELYN OGBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

1401 15TH ST S
FARGO ND
58103-3925
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-9912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH6492
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: