Provider Demographics
NPI:1679328223
Name:ANDERSON, KAILEY
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9519 RIVER FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-3336
Mailing Address - Country:US
Mailing Address - Phone:763-732-8917
Mailing Address - Fax:
Practice Address - Street 1:12567 5TH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-8453
Practice Address - Country:US
Practice Address - Phone:763-856-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2507658163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse