Provider Demographics
NPI:1366992323
Name:FOUR SEASONS WELLNESS, PLLC
Entity type:Organization
Organization Name:FOUR SEASONS WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:RATH
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:701-475-4488
Mailing Address - Street 1:110 W BROADWAY
Mailing Address - Street 2:PO BOX 397
Mailing Address - City:STEELE
Mailing Address - State:ND
Mailing Address - Zip Code:58482-7109
Mailing Address - Country:US
Mailing Address - Phone:701-475-4488
Mailing Address - Fax:701-540-6379
Practice Address - Street 1:110 W BROADWAY
Practice Address - Street 2:
Practice Address - City:STEELE
Practice Address - State:ND
Practice Address - Zip Code:58482-7109
Practice Address - Country:US
Practice Address - Phone:701-475-4488
Practice Address - Fax:701-540-6379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR28545261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1386964138Medicaid