Healthcare Provider Details

I. General information

NPI: 1821769159
Provider Name (Legal Business Name): NORTH STAR FAMILY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 14TH ST W STE 230
WILLISTON ND
58801-4078
US

IV. Provider business mailing address

3620 6TH AVE E
WILLISTON ND
58801-6360
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-0390
  • Fax: 701-774-0391
Mailing address:
  • Phone: 701-774-0390
  • Fax: 701-774-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRANDY SHAHIN
Title or Position: OWNER
Credential: FNP-C
Phone: 701-774-0390