Healthcare Provider Details

I. General information

NPI: 1609605435
Provider Name (Legal Business Name): SHAENA KUCH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 06/16/2025
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALTRU PROFESSIONAL CENTER 4440 S. WASHINGTON ST.
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 218-368-0728
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200347
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: