Provider Demographics
NPI:1477970846
Name:MINOT HEALTH CLINIC, PLLC
Entity Type:Organization
Organization Name:MINOT HEALTH CLINIC, PLLC
Other - Org Name:MINOT HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNERN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:701-837-1551
Mailing Address - Street 1:1021 20TH AVE SW STE 113
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6487
Mailing Address - Country:US
Mailing Address - Phone:701-837-1551
Mailing Address - Fax:701-837-1540
Practice Address - Street 1:1021 20TH AVE SW STE 113
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6487
Practice Address - Country:US
Practice Address - Phone:701-837-1551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30827261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND715283OtherMEDICARE
ND1013220490OtherBCBS
ND84015Medicaid