Provider Demographics
NPI:1699833301
Name:FENSTAD, BROOKE ERIN (OD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:ERIN
Last Name:FENSTAD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4546 44TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3980
Mailing Address - Country:US
Mailing Address - Phone:701-238-7484
Mailing Address - Fax:
Practice Address - Street 1:I-29 AND 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-277-9555
Practice Address - Fax:701-277-7112
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist