Provider Demographics
NPI:1841764453
Name:KITTELSON, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:KITTELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 SPRUCE PL APT 1207
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2753
Mailing Address - Country:US
Mailing Address - Phone:612-245-4843
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-245-4832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer