Healthcare Provider Details

I. General information

NPI: 1225158488
Provider Name (Legal Business Name): DALE KEN FITZKE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVE NE
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

132 14TH AVE NE
DEVILS LAKE ND
58301-3301
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1600
  • Fax: 701-766-1626
Mailing address:
  • Phone: 701-662-4566
  • Fax: 701-766-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR29497
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: