Provider Demographics
NPI:1407497548
Name:MIDDENDORF, KAYLA (DC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1413
Mailing Address - Country:US
Mailing Address - Phone:320-429-0044
Mailing Address - Fax:
Practice Address - Street 1:1777 BUNKER LAKE BLVD NW # 200
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4008
Practice Address - Country:US
Practice Address - Phone:763-413-6934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor