Provider Demographics
NPI:1154319911
Name:HALVERSON, GAIL RAE (NP)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:RAE
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18408 430TH SWAVE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-9257
Mailing Address - Country:US
Mailing Address - Phone:701-739-1820
Mailing Address - Fax:218-773-1560
Practice Address - Street 1:360 DIVISION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4702
Practice Address - Country:US
Practice Address - Phone:701-775-4251
Practice Address - Fax:701-775-3691
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR29615363LW0102X
MNR118302-3363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND53595Medicaid