Provider Demographics
NPI:1225348352
Name:KRAGENBRING, MARK OLIVER (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:OLIVER
Last Name:KRAGENBRING
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 SHADY OAKS RD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:MN
Mailing Address - Zip Code:56209-9365
Mailing Address - Country:US
Mailing Address - Phone:320-974-8266
Mailing Address - Fax:
Practice Address - Street 1:5501 SHADY OAKS RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:MN
Practice Address - Zip Code:56209-9365
Practice Address - Country:US
Practice Address - Phone:320-974-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1279678163W00000X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse