Provider Demographics
NPI:1063293967
Name:GLEAM AESTHETIC PLLC
Entity type:Organization
Organization Name:GLEAM AESTHETIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:701-840-0706
Mailing Address - Street 1:11682 35M ST SE
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-9522
Mailing Address - Country:US
Mailing Address - Phone:701-840-0706
Mailing Address - Fax:
Practice Address - Street 1:202 CENTRAL AVE S STE 8
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3325
Practice Address - Country:US
Practice Address - Phone:701-840-0706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center