Provider Demographics
NPI:1003479965
Name:WALSH, KATELYNN MARIE (MS, LAT, ATC, EMT)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:MS, LAT, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 282
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-0282
Mailing Address - Country:US
Mailing Address - Phone:952-843-8505
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-843-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN33592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPMU124738036001OtherBLUE CROSS BLUE SHIELD