Basic Information
| Provider Information | |||||||||
| NPI: | 1346417508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STELLON | ||||||||
| FirstName: | KRIS | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAGNER | ||||||||
| OtherFirstName: | KRIS | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN-CNS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 S COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805000 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805000 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 364S00000X | R31275 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.