Provider Demographics
NPI:1023358546
Name:RUNKLE, KAYLA JANE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:JANE
Last Name:RUNKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9875 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4648
Mailing Address - Country:US
Mailing Address - Phone:763-581-1000
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:9875 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-581-1000
Practice Address - Fax:763-450-3986
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 167267-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered