Individual
MADISON LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1108 S 9TH ST, GRAND FORKS, ND 58201-5570
(218) 689-9517
Mailing address
1108 S 9TH ST, GRAND FORKS, ND 58201-5570
(218) 689-9517
Taxonomy
Speciality
Code
Description
License number
State
376K00000X
Nurse's Aide
70560
ND
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
ND
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
03/30/2021
Last updated
02/18/2026
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