Provider Demographics
NPI:1982955159
Name:MOEN, LISA ROSE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROSE
Last Name:MOEN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ROSE
Other - Last Name:HOFFARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:701-232-3241
Mailing Address - Fax:701-237-2637
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:701-237-2637
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34505363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND84203Medicaid
NDN718340Medicare PIN