Provider Demographics
NPI:1225631799
Name:NELSON, KATHLEEN DIANA
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANA
Last Name:NELSON
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:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ND
Mailing Address - Zip Code:58338-0132
Mailing Address - Country:US
Mailing Address - Phone:701-370-0558
Mailing Address - Fax:
Practice Address - Street 1:124 BIRCH ST
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ND
Practice Address - Zip Code:58338-3801
Practice Address - Country:US
Practice Address - Phone:701-370-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant