Provider Demographics
NPI: | 1437565330 |
---|---|
Name: | DAHL, CHRISTINA (FNP-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRISTINA |
Middle Name: | |
Last Name: | DAHL |
Suffix: | |
Gender: | F |
Credentials: | FNP-C |
Other - Prefix: | |
Other - First Name: | CHRISTINA |
Other - Middle Name: | |
Other - Last Name: | MJONESS |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | |
Mailing Address - Street 1: | 3453 INTERSTATE BLVD S STE B |
Mailing Address - Street 2: | |
Mailing Address - City: | FARGO |
Mailing Address - State: | ND |
Mailing Address - Zip Code: | 58103-2257 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 701-205-4533 |
Mailing Address - Fax: | 701-205-4593 |
Practice Address - Street 1: | 1665 43RD ST S STE 102 |
Practice Address - Street 2: | |
Practice Address - City: | FARGO |
Practice Address - State: | ND |
Practice Address - Zip Code: | 58103-3316 |
Practice Address - Country: | US |
Practice Address - Phone: | 701-289-5469 |
Practice Address - Fax: | 701-540-9824 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-07-11 |
Last Update Date: | 2020-02-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ND | R26447 | 363L00000X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ND | 84359 | Medicaid |