Healthcare Provider Details

I. General information

NPI: 1104751320
Provider Name (Legal Business Name): BETHANY JOHNSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY SANDY

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

5225 23RD AVE S
FARGO ND
58104-7927
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2251
  • Fax:
Mailing address:
  • Phone: 701-417-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number205339
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number205339
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: