Provider Demographics
NPI:1710655873
Name:NIEDERKORN, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:NIEDERKORN
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 58
Mailing Address - Street 2:
Mailing Address - City:HENDRUM
Mailing Address - State:MN
Mailing Address - Zip Code:56550-0058
Mailing Address - Country:US
Mailing Address - Phone:763-228-8148
Mailing Address - Fax:
Practice Address - Street 1:1530 1ST AVE N STE 150
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2278
Practice Address - Country:US
Practice Address - Phone:763-228-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other