Provider Demographics
NPI:1568475010
Name:KASSULKE, DEBRA A (CNM)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:KASSULKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BLOOMINGTON AVE
Mailing Address - Street 2:CUHHC
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-638-0700
Mailing Address - Fax:
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:CUHHC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-638-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR088923-4176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife