Healthcare Provider Details

I. General information

NPI: 1093835472
Provider Name (Legal Business Name): MARY LOUISE RISKE RN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 COLUMBIA RD. STOP 9037
GRAND FORKS ND
58202-9037
US

IV. Provider business mailing address

2404 S 40TH ST
GRAND FORKS ND
58201-5948
US

V. Phone/Fax

Practice location:
  • Phone: 701-777-4243
  • Fax:
Mailing address:
  • Phone: 701-746-0375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR18963
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: