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General NPI Number Information
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NPI Number | 1619939006
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Entity Type | Individual
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Provider Name | CAROL SUE MOEN NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 04/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 524 4TH AVE NE UNIT 9
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City | DEVILS LAKE
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State | ND
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Zip | 58301-2490
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Country | US
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Telephone | 701-662-7046
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Fax |
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Provider Business Mailing Address
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Address Line | 5312 118TH AVE NE
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City | MICHIGAN
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State | ND
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Zip | 58259-9452
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Country | US
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Telephone | 701-259-2339
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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 | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | R20055
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License Number State | ND
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