Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | R40018 | ND |
NPI | 1083368054 |
---|---|
Provider Name | Breanna Dinae Mohagen |
First Address | West Fargo, ND 58078-8046 |
Second Address | Fargo, ND 58103-4499 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2022 |
Last Update Date | 09/02/2022 |