Healthcare Provider Details

I. General information

NPI: 1659154706
Provider Name (Legal Business Name): RUSSELL JAMES NIFFENEGGER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RUSSELL MILTON WILLIS

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
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

1079 DEER TRAIL LN NE
THOMPSON ND
58278-9400
US

V. Phone/Fax

Practice location:
  • Phone: 701-516-4637
  • Fax: 877-651-1381
Mailing address:
  • Phone: 701-740-9272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR42886
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: