Healthcare Provider Details

I. General information

NPI: 1619850831
Provider Name (Legal Business Name): QUEEN ELIZABETH FUGAH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 15TH AVE W
WILLISTON ND
58801-3800
US

IV. Provider business mailing address

13785 MARIONS RIDGE RD
WILLISTON ND
58801-9589
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7651
  • Fax:
Mailing address:
  • Phone: 850-319-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202964
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: