Healthcare Provider Details

I. General information

NPI: 1265093124
Provider Name (Legal Business Name): MCKENZIE ANN DISRUD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKENZIE ANN BROWN

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S COLUMBIA RD STE 114
GRAND FORKS ND
58201-5895
US

IV. Provider business mailing address

PO BOX 13238
GRAND FORKS ND
58208-3238
US

V. Phone/Fax

Practice location:
  • Phone: 701-516-4637
  • Fax: 877-651-1381
Mailing address:
  • Phone: 15-164-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06191893
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRH1306
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: