Provider Demographics
NPI:1659412609
Name:SANDELL, KATHRYN JANE (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANE
Last Name:SANDELL
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 GREYSOLON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-2206
Mailing Address - Country:US
Mailing Address - Phone:219-724-9613
Mailing Address - Fax:
Practice Address - Street 1:2322 GREYSOLON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-2206
Practice Address - Country:US
Practice Address - Phone:218-724-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1118645163W00000X
MNCNM0160367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN369169100Medicaid