Provider Demographics
NPI:1831473263
Name:MAGEE, ELIZABETH ANN GILLHAM (LRD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH ANN
Middle Name:GILLHAM
Last Name:MAGEE
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:ELIZABETH ANN
Other - Middle Name:G
Other - Last Name:FREDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3955 56TH ST S STE D
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4845
Practice Address - Country:US
Practice Address - Phone:701-417-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND856133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56268Medicaid
ND55931Medicaid
NDN717244Medicare PIN
ND55931Medicaid