Healthcare Provider Details

I. General information

NPI: 1770072837
Provider Name (Legal Business Name): KELSEY ANN WISEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE
HAZEN ND
58545-4637
US

IV. Provider business mailing address

617 4TH ST NE
HAZEN ND
58545-4606
US

V. Phone/Fax

Practice location:
  • Phone: 701-873-4445
  • Fax:
Mailing address:
  • Phone: 701-648-9649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17267
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: