Healthcare Provider Details

I. General information

NPI: 1336060698
Provider Name (Legal Business Name): FELICIA GREYWATER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 3RD AVE N
FORT TOTTEN ND
58335-9998
US

IV. Provider business mailing address

816 3RD AVE N
FORT TOTTEN ND
58335-9998
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-4236
  • Fax: 701-766-4878
Mailing address:
  • Phone: 701-766-4236
  • Fax: 701-766-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: