Healthcare Provider Details

I. General information

NPI: 1619281987
Provider Name (Legal Business Name): HEIDI LYNN GRONDAHL WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 W DAKOTA PKWY
WILLISTON ND
58801-3807
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7711
  • Fax: 701-572-2283
Mailing address:
  • Phone: 701-857-5118
  • Fax: 701-857-3430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR-198574-2
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR31608
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: