Provider Demographics
NPI:1710574629
Name:KNUDSON, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:KNUDSON
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:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:ESMOND
Mailing Address - State:ND
Mailing Address - Zip Code:58332-0122
Mailing Address - Country:US
Mailing Address - Phone:701-230-8272
Mailing Address - Fax:
Practice Address - Street 1:121 ALTA AVE N
Practice Address - Street 2:
Practice Address - City:ESMOND
Practice Address - State:ND
Practice Address - Zip Code:58332-5833
Practice Address - Country:US
Practice Address - Phone:701-230-8272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker