Healthcare Provider Details

I. General information

NPI: 1750215349
Provider Name (Legal Business Name): NICOLETTE HARGRAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W BROADWAY STE 202
WILLISTON ND
58801-6056
US

IV. Provider business mailing address

110 W BROADWAY STE 202
WILLISTON ND
58801-6056
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-6300
  • Fax: 701-774-6300
Mailing address:
  • Phone: 701-774-6300
  • Fax: 701-774-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberNDL-16-6827
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: