Provider Demographics
NPI:1861124760
Name:MORIN, MANDY RAE
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:RAE
Last Name:MORIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4169 ND-5
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316
Mailing Address - Country:US
Mailing Address - Phone:701-630-5704
Mailing Address - Fax:
Practice Address - Street 1:10115 42ND AVE NE
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-630-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND73234251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDND-3391809Medicaid