Healthcare Provider Details

I. General information

NPI: 1801141049
Provider Name (Legal Business Name): JESSICA MARIE KOTRBA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 S COLUMBIA RD - ALTRU FAMILY MEDICINE CENTER
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-795-2000
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR30337
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR30337
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: