Healthcare Provider Details

I. General information

NPI: 1386280261
Provider Name (Legal Business Name): CANOPY MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 32ND ST S STE 1
FARGO ND
58103-6304
US

IV. Provider business mailing address

1411 32ND ST S STE 1
FARGO ND
58103-6304
US

V. Phone/Fax

Practice location:
  • Phone: 701-306-0943
  • Fax:
Mailing address:
  • Phone: 701-264-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HEIDI SELZLER-ECHOLA
Title or Position: MEDICAL DIRECTOR
Credential: APRN
Phone: 701-264-5200