Provider Demographics
NPI:1750500054
Name:RUSTEBAKKE, KATHRYN GAIL (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GAIL
Last Name:RUSTEBAKKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:701 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4506
Practice Address - Country:US
Practice Address - Phone:701-772-2200
Practice Address - Fax:701-772-2800
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
28850OtherBLUE CROSS BLUE SHIELD
64-08167OtherMEDICA
ND55119Medicaid
B17461052130OtherPREFERRED ONE
5335800001Medicare PIN
712880Medicare PIN