Healthcare Provider Details

I. General information

NPI: 1710808985
Provider Name (Legal Business Name): CRYSTAL A LUNDMARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 VIVIAN ST W
PARK RIVER ND
58270-4540
US

IV. Provider business mailing address

3532 11TH AVE N APT 10
GRAND FORKS ND
58203-2152
US

V. Phone/Fax

Practice location:
  • Phone: 701-317-0067
  • Fax:
Mailing address:
  • Phone: 701-317-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: