Healthcare Provider Details

I. General information

NPI: 1306836937
Provider Name (Legal Business Name): ELIZABETH ANN TYREE RN, PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVENUE NORTH AND HARVARD STREETS
GRAND FORKS ND
58202
US

IV. Provider business mailing address

710 N 25TH ST
GRAND FORKS ND
58203-2945
US

V. Phone/Fax

Practice location:
  • Phone: 701-777-4522
  • Fax: 701-777-4096
Mailing address:
  • Phone: 701-746-7802
  • Fax: 701-777-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberR24430
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: