Basic Information
| Provider Information | |||||||||
| NPI: | 1962605162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | METELMANN | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN CDE | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582066002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805340 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SOUTH COLUMBIA ROAD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582066002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805340 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | RNR19204 | ND | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator | 163WD0400X | RNR1499555 | MN | N | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 22220347 | 01 | NATIONAL | OTHER |