Healthcare Provider Details

I. General information

NPI: 1134417140
Provider Name (Legal Business Name): PENNI MARIE WESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 13TH AVE S
FARGO ND
58103-3357
US

IV. Provider business mailing address

1702 UNIVERSITY DRIVE SOUTH ATTN: SSC
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-6600
  • Fax: 701-364-6628
Mailing address:
  • Phone: 701-364-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR20495
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: