Healthcare Provider Details

I. General information

NPI: 1437643533
Provider Name (Legal Business Name): CARRIE NELSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 CENTENNIAL BLVD
FARGO ND
58102
US

IV. Provider business mailing address

1707 CENTENNIAL BLVD
FARGO ND
58102-6050
US

V. Phone/Fax

Practice location:
  • Phone: 701-231-7331
  • Fax:
Mailing address:
  • Phone: 701-231-7331
  • Fax: 701-231-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR37871
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: