Healthcare Provider Details

I. General information

NPI: 1558799015
Provider Name (Legal Business Name): CARRIE MECKLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2013
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NORTH RIVER ROAD
FT YATES ND
58538
US

IV. Provider business mailing address

10 N RIVER ROAD
FORT YATES ND
58538
US

V. Phone/Fax

Practice location:
  • Phone: 701-854-8347
  • Fax:
Mailing address:
  • Phone: 701-854-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR31367
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: