Provider Demographics
NPI:1467719864
Name:KALLESTAD, KRISTEN MARIE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:KALLESTAD
Suffix:
Gender:F
Credentials:MD, PHD
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 718
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:MN
Mailing Address - Zip Code:55395-0718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 4TH ST N
Practice Address - Street 2:
Practice Address - City:WINSTED
Practice Address - State:MN
Practice Address - Zip Code:55395-4523
Practice Address - Country:US
Practice Address - Phone:952-442-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty