Healthcare Provider Details

I. General information

NPI: 1356439053
Provider Name (Legal Business Name): GRACIA ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

IV. Provider business mailing address

904 5TH AVE NE
JAMESTOWN ND
58401-3437
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-7492
  • Fax: 701-774-7479
Mailing address:
  • Phone: 701-253-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number702
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: