Provider Demographics
NPI:1801412929
Name:LATENDRESSE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LATENDRESSE
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:PO BOX 2209
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-2209
Mailing Address - Country:US
Mailing Address - Phone:701-857-0715
Mailing Address - Fax:
Practice Address - Street 1:225 3RD ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3958
Practice Address - Country:US
Practice Address - Phone:701-857-0715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator