=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922693464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH HERMES RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2021
-----------------------------------------------------
Last Update Date | 03/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 387 11TH ST S OFC 2
-----------------------------------------------------
City | WAHPETON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58075-4677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-642-2336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16260 55TH ST SE
-----------------------------------------------------
City | KINDRED
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58051-9521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-866-0509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R17291
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------