Provider Demographics
NPI:1619107380
Name:LESSARD, COLLETTE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLETTE
Middle Name:RAE
Last Name:LESSARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COLLETTE
Other - Middle Name:RAE
Other - Last Name:LESSARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1380 S COLUMBIA RD - ALTRU FAMILY MEDICINE CENTER
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-795-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12836207V00000X, 207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
NDN719046Medicare UPIN
MNENROLLEDMedicaid