Provider Demographics
NPI:1669014445
Name:DIX, KAYLAN RAE (CNP)
Entity Type:Individual
Prefix:
First Name:KAYLAN
Middle Name:RAE
Last Name:DIX
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KAYLAN
Other - Middle Name:RAE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2831 SNELLING AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1712
Mailing Address - Country:US
Mailing Address - Phone:651-765-5900
Mailing Address - Fax:
Practice Address - Street 1:576 APOLLO DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-3004
Practice Address - Country:US
Practice Address - Phone:651-486-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily