Basic Information
| Provider Information | |||||||||
| NPI: | 1356871693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | ROSE DYBDAL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 DELMORE DR | ||||||||
| Address2: | |||||||||
| City: | ROSEAU | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184631365 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MRM-1662 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 67554 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.