Healthcare Provider Details

I. General information

NPI: 1053398909
Provider Name (Legal Business Name): CATHIE SUE HENNEBERRY F.N.P., APRN-BC, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CATHIE SUE GWIN-HENNEBERRY FNP-BC

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 15TH AVE W
WILLISTON ND
58801
US

IV. Provider business mailing address

1213 15TH AVE W
WILLISTON ND
58801-3800
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7651
  • Fax:
Mailing address:
  • Phone: 701-572-7651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN26836
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR36163
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: