Healthcare Provider Details

I. General information

NPI: 1144908625
Provider Name (Legal Business Name): TRACI SPECHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
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: 701-516-4637
  • Fax: 877-651-1381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR31830
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: