Provider Demographics
NPI:1619578648
Name:BAKER, KANIKA LANESE
Entity Type:Individual
Prefix:
First Name:KANIKA
Middle Name:LANESE
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12526 74TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5290
Mailing Address - Country:US
Mailing Address - Phone:612-458-7857
Mailing Address - Fax:
Practice Address - Street 1:7240 BROOKLYN BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55429-1274
Practice Address - Country:US
Practice Address - Phone:888-507-6235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18438613335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier