Healthcare Provider Details

I. General information

NPI: 1356846422
Provider Name (Legal Business Name): ANGELA MATHSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 2ND AVE W
WILLISTON ND
58801-5218
US

IV. Provider business mailing address

PO BOX 1266
WILLISTON ND
58802-1266
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax:
Mailing address:
  • Phone: 701-774-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR45157
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: