Healthcare Provider Details

I. General information

NPI: 1700743366
Provider Name (Legal Business Name): AMANDA L GARD MLS(ASCP)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BROADWAY N
FARGO ND
58102-1406
US

IV. Provider business mailing address

2601 BROADWAY N
FARGO ND
58102-1406
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2992
  • Fax:
Mailing address:
  • Phone: 701-234-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number25-1298-I
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: