Provider Demographics
NPI:1467190371
Name:HENNINGSON, KYA MICHELLE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:KYA
Middle Name:MICHELLE
Last Name:HENNINGSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:KYA
Other - Middle Name:MICHELLE
Other - Last Name:PICHA-HOLLISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CNP
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:20118 COUNTY ROAD 12
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MN
Practice Address - Zip Code:56455-2048
Practice Address - Country:US
Practice Address - Phone:763-221-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-22
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily