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General NPI Number Information
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NPI Number | 1265093124
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Entity Type | Individual
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Provider Name | MCKENZIE ANN DISRUD FNP
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Gender | Female
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Dates
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Enumeration Date | 06/21/2019
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 2100 S COLUMBIA RD STE 114
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City | GRAND FORKS
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State | ND
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Zip | 58201-5895
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Country | US
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Telephone | 701-516-4637
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Fax | 877-651-1381
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Provider Business Mailing Address
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Address Line | PO BOX 13238
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City | GRAND FORKS
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State | ND
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Zip | 58208-3238
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Country | US
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Telephone | 15-164-6377
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F06191893
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License Number State | ND
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RH1306
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License Number State | ND
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