Provider Demographics
NPI:1083368054
Name:MOHAGEN, BREANNA DINAE (APRN)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:DINAE
Last Name:MOHAGEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 BLUESTEM DR APT 3199
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8046
Mailing Address - Country:US
Mailing Address - Phone:701-936-5488
Mailing Address - Fax:
Practice Address - Street 1:1701 38TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-356-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR40018363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology