Healthcare Provider Details

I. General information

NPI: 1174749501
Provider Name (Legal Business Name): SHERRIE R. LANDSEM WALFORD MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVENUE NE BOX 309
FORT TOTTEN ND
58335-0309
US

IV. Provider business mailing address

1100 AVENUE A
DEVILS LAKE ND
58301-6002
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1600
  • Fax: 701-766-1640
Mailing address:
  • Phone: 701-662-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: