Provider Demographics
NPI:1710597091
Name:VISTAD, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:VISTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-1934
Mailing Address - Country:US
Mailing Address - Phone:701-739-6262
Mailing Address - Fax:
Practice Address - Street 1:1220 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-1934
Practice Address - Country:US
Practice Address - Phone:701-739-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program