MEDICARE: ROSE I BRAKKE AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	989	ND

General Provider Information

NPI Number	:	1023297348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE I BRAKKE AUD

Provider Business Mailing Address
First Line	:	3139 BLUE STEM DR STE 108
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-8060
Country	:	US
Telephone Number	:	701-639-4595
Fax Number	:	701-639-6979

Provider Business Practice Location Address
First Line	:	3139 BLUE STEM DR STE 108
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-8060
Country	:	US
Telephone Number	:	701-639-4595
Fax Number	:	701-639-6979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	01/05/2017

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Directions to “ ROSE I BRAKKE AUD” Practice Location

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