Provider Demographics
NPI:1548383664
Name:KALLA, IMO I (NP)
Entity Type:Individual
Prefix:
First Name:IMO
Middle Name:I
Last Name:KALLA
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:FREEPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:320-203-2113
Practice Address - Street 1:2251 CONNECTICUT AVENUE S
Practice Address - Street 2:HP CENTRAL MN CLINICS
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2486
Practice Address - Country:US
Practice Address - Phone:320-253-5220
Practice Address - Fax:320-203-2113
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2011-12-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR118728-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN177515400Medicaid
MNS46320Medicare UPIN
MN177515400Medicaid
MN500000543Medicare ID - Type Unspecified