Healthcare Provider Details

I. General information

NPI: 1083532261
Provider Name (Legal Business Name): BRYN VETTLESON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

151 S 4TH ST
GRAND FORKS ND
58201-4715
US

IV. Provider business mailing address

151 S 4TH ST
GRAND FORKS ND
58201-4715
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax: --
Mailing address:
  • Phone: --
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: