Provider Demographics
NPI:1265093124
Name:DISRUD, MCKENZIE ANN (FNP)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:ANN
Last Name:DISRUD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:ANN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13238
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208-3238
Mailing Address - Country:US
Mailing Address - Phone:015-164-6377
Mailing Address - Fax:
Practice Address - Street 1:2100 S COLUMBIA RD STE 114
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-516-4637
Practice Address - Fax:877-651-1381
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
NDF06191893363LF0000X
NDRH1306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical