Healthcare Provider Details

I. General information

NPI: 1396948493
Provider Name (Legal Business Name): LYNN M HOLUM LRD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HAMLINE ST - ALTRU FAMILY MEDICINE RESIDENCY
GRAND FORKS ND
58203
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6400
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number520
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: