Provider Demographics
NPI:1336900356
Name:CHRISTENSEN, HEAVENLY LACE
Entity Type:Individual
Prefix:
First Name:HEAVENLY
Middle Name:LACE
Last Name:CHRISTENSEN
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 1:921 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1705
Mailing Address - Country:US
Mailing Address - Phone:701-318-8204
Mailing Address - Fax:
Practice Address - Street 1:921 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1705
Practice Address - Country:US
Practice Address - Phone:701-318-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND448175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist