MEDICARE: JAEDA KERIN ERTELT FNP-C

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	363LF0000X	Family Nurse Practitioner	R36635	ND

General Provider Information

NPI Number	:	1063062693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAEDA KERIN ERTELT FNP-C

Provider Business Mailing Address
First Line	:	726 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3304
Country	:	US
Telephone Number	:	701-510-2010
Fax Number	:	844-689-2048

Provider Business Practice Location Address
First Line	:	726 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3304
Country	:	US
Telephone Number	:	701-510-2010
Fax Number	:	844-689-2048

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

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	03/11/2026

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