Basic Information
| Provider Information | |||||||||
| NPI: | 1154817856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEMMING | ||||||||
| FirstName: | HEAVEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GUSTAFSON | ||||||||
| OtherFirstName: | HEAVEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013644222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2018 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2078221 | MN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 5997 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.