Healthcare Provider Details

I. General information

NPI: 1669793410
Provider Name (Legal Business Name): STACIE MARIE WELLMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

IV. Provider business mailing address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

V. Phone/Fax

Practice location:
  • Phone: 701-567-4561
  • Fax:
Mailing address:
  • Phone: 701-567-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8897
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12893
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14041
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68454
License Number StateMT
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19227
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: