Provider Demographics
NPI:1356439053
Name:ERICKSON, GRACIA
Entity type:Individual
Prefix:
First Name:GRACIA
Middle Name:
Last Name:ERICKSON
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 1:904 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3437
Mailing Address - Country:US
Mailing Address - Phone:701-253-4000
Mailing Address - Fax:
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7492
Practice Address - Fax:701-774-7479
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND702133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered