Healthcare Provider Details

I. General information

NPI: 1821402512
Provider Name (Legal Business Name): NICOLE MORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 17TH ST S
FARGO ND
58103-2557
US

IV. Provider business mailing address

817 17TH ST S
FARGO ND
58103-2557
US

V. Phone/Fax

Practice location:
  • Phone: 218-790-5433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberL12052
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: