Healthcare Provider Details

I. General information

NPI: 1649726241
Provider Name (Legal Business Name): KELSEY HEGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 FOREST ST
LISBON ND
58054-4136
US

IV. Provider business mailing address

404 FOREST ST PO BOX 89
LISBON ND
58054
US

V. Phone/Fax

Practice location:
  • Phone: 701-683-6170
  • Fax: 701-683-6168
Mailing address:
  • Phone: 701-683-6170
  • Fax: 701-683-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR37270
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: