Healthcare Provider Details

I. General information

NPI: 1811311814
Provider Name (Legal Business Name): SARA MUTZENBERGER CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 S COLUMBIA RD
GRAND FORKS ND
58201-4059
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 Code163W00000X
TaxonomyRegistered Nurse
License NumberR34242
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: