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General NPI Number Information
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NPI Number | 1083368054
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Entity Type | Individual
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Provider Name | BREANNA DINAE MOHAGEN APRN
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Gender | Female
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Dates
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Enumeration Date | 02/09/2022
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Last Update Date | 02/09/2022
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Provider Practice Location Address
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Address Line | 1701 38TH ST S
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City | FARGO
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State | ND
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Zip | 58103-4499
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Country | US
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Telephone | 701-356-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 2915 BLUESTEM DR APT 3199
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City | WEST FARGO
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State | ND
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Zip | 58078-8046
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Country | US
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Telephone | 701-936-5488
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | R40018
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License Number State | ND
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