Healthcare Provider Details

I. General information

NPI: 1659795995
Provider Name (Legal Business Name): JUDY DALZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST
MANDAN ND
58554-3146
US

IV. Provider business mailing address

1513 OAKLAND DR
BISMARCK ND
58504-6445
US

V. Phone/Fax

Practice location:
  • Phone: 704-669-5373
  • Fax: 701-663-0102
Mailing address:
  • Phone: 701-223-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR19707
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR19707
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: