Provider Demographics
NPI:1659417962
Name:FOKKEN, KATIE (DC)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:
Last Name:FOKKEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 LANCASTER LN N STE 110
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1702
Mailing Address - Country:US
Mailing Address - Phone:763-551-1344
Mailing Address - Fax:
Practice Address - Street 1:4205 LANCASTER LN N STE 110
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-1702
Practice Address - Country:US
Practice Address - Phone:763-551-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4545111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNV08273Medicare UPIN