Healthcare Provider Details

I. General information

NPI: 1689505158
Provider Name (Legal Business Name): CHEYENNE ROSE CLINTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

IV. Provider business mailing address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-7090
  • Fax: 701-572-1685
Mailing address:
  • Phone: 701-774-7090
  • Fax: 701-572-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number2003419
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: