Healthcare Provider Details

I. General information

NPI: 1427514165
Provider Name (Legal Business Name): JOSEPH JAMES LENNON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

442 FOXTAIL DR
WEST FARGO ND
58078-7964
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax:
Mailing address:
  • Phone: 218-838-3453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR38592
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: