Provider Demographics
NPI:1992989057
Name:SLETVOLD, MICHELLE A (BSED)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:SLETVOLD
Suffix:
Gender:F
Credentials:BSED
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:HAGGERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 PULVER HALL
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4857
Mailing Address - Country:US
Mailing Address - Phone:701-227-7582
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:200 PULVER HALL
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4857
Practice Address - Country:US
Practice Address - Phone:701-227-7582
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ND514183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid