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General NPI Number Information
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NPI Number | 1063293967
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Entity Type | Organization
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Legal Business Name | GLEAM AESTHETIC PLLC
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Dates
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Enumeration Date | 10/09/2023
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Last Update Date | 10/09/2023
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Provider Practice Location Address
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Address Line | 202 CENTRAL AVE S STE 8
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City | VALLEY CITY
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State | ND
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Zip | 58072-3325
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Country | US
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Telephone | 701-840-0706
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Fax |
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Provider Business Mailing Address
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Address Line | 11682 35M ST SE
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City | VALLEY CITY
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State | ND
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Zip | 58072-9522
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Country | US
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Telephone | 701-840-0706
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER/OWNER
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Name | SARAH HANSEN
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Credential | FNP-C
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Telephone | 701-840-0706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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