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1132 28th Ave S Ste 102 Moorhead MN 56560-4420 | |
| (218) 512-0630 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 1132 28th Ave S Ste 102, Moorhead, Minnesota |
| Authorized Official Name and Position | Amy Lavalla (ADMINISTRATOR) |
| Authorized Official Contact | 2185120630 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1132 28th Ave S Ste 102 Moorhead MN 56560-4420 Ph: (218) 512-0630 | 1132 28th Ave S Ste 102 Moorhead MN 56560-4420 Ph: (218) 512-0630 |
| NPI Number | 1285352872 |
|---|---|
| Provider Enumeration Date | 08/18/2022 |
| Last Update Date | 12/30/2022 |
| Certification Date | 12/30/2022 |
| Medicare PECOS PAC ID | 2466821251 |
|---|---|
| Medicare Enrollment ID | O20221219000984 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1285352872 | NPI | - | NPPES |
| Provider Name | Amy J Lavalla |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1215312236 PECOS PAC ID: 8224344890 Enrollment ID: I20160510001346 |
| Provider Name | Jordan Coles |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1902245665 PECOS PAC ID: 5496198764 Enrollment ID: I20240205000736 |
| Provider Name | Alecsis Makay Zimmer |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1265067268 PECOS PAC ID: 9830534957 Enrollment ID: I20240228004078 |
| Provider Name | Stephanie Akers |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1609443597 PECOS PAC ID: 3274916473 Enrollment ID: I20241015002706 |
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