Healthcare Provider Details

I. General information

NPI: 1861390262
Provider Name (Legal Business Name): ELISE SERENE SPEARS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2026
Last Update Date: 10/27/2026
Certification Date: 10/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 44TH AVE S
FARGO ND
58104-6674
US

IV. Provider business mailing address

269 31ST AVE E APT 25
WEST FARGO ND
58078-8335
US

V. Phone/Fax

Practice location:
  • Phone: 701-550-6037
  • Fax:
Mailing address:
  • Phone: 701-550-6037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: