Provider Demographics
NPI:1730863937
Name:GRETTUM, CAROL (CP, CPED)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:GRETTUM
Suffix:
Gender:F
Credentials:CP, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 32ND AVE W APT 602
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2947
Mailing Address - Country:US
Mailing Address - Phone:701-261-6601
Mailing Address - Fax:
Practice Address - Street 1:FARGO VA HEALTHCARE SYSTEM
Practice Address - Street 2:2101 ELM STREET N
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:701-239-3721
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist