Healthcare Provider Details

I. General information

NPI: 1780234377
Provider Name (Legal Business Name): LISA AMUNDGAARD-PAGNAC PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 11/21/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALTRU 860 COLUMBIA 860 S COLUMBIA ROAD
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6697
  • Fax:
Mailing address:
  • Phone: 701-795-3000
  • Fax: 701-795-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR32263
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11822
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200852
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: