Healthcare Provider Details

I. General information

NPI: 1649215070
Provider Name (Legal Business Name): VICKIE K WEATHERS CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 5TH AVE SE SUITE 502
MINOT ND
58701-4784
US

IV. Provider business mailing address

1705 4TH AVE NW
MINOT ND
58703-2912
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-2199
  • Fax: 701-857-2199
Mailing address:
  • Phone: 701-839-0474
  • Fax: 701-839-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number0388003-02
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR28599
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberL9274
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: