Provider Demographics
NPI:1194379214
Name:KITTLESON, TAMARA LEA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LEA
Last Name:KITTLESON
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 1:5520 ALDRICH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1734
Mailing Address - Country:US
Mailing Address - Phone:612-327-0803
Mailing Address - Fax:
Practice Address - Street 1:6600 FRANCE AVE S STE 415
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1804
Practice Address - Country:US
Practice Address - Phone:952-303-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6765363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health