Provider Demographics
NPI:1134107444
Name:KALLESTAD, KIM (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:KALLESTAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6900
Mailing Address - Country:US
Mailing Address - Phone:406-587-0704
Mailing Address - Fax:406-587-1147
Practice Address - Street 1:925 HIGHLAND BLVD
Practice Address - Street 2:SUITE 1200
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6900
Practice Address - Country:US
Practice Address - Phone:406-587-0704
Practice Address - Fax:406-587-1147
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN15264163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse