Basic Information
Provider Information | |||||||||
NPI: | 1043316524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALVITSCH | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KARY | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5501 | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585065501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013236000 | ||||||||
FaxNumber: | 7013235709 | ||||||||
Practice Location | |||||||||
Address1: | 414 N 7TH ST | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585014423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013236549 | ||||||||
FaxNumber: | 7013235492 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 01/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R25536 | ND | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 19603 | 05 | ND |   | MEDICAID |