Provider Demographics
NPI:1992365498
Name:GALLAIS, KATHLEEN YVETTE (LAT, ATC, NREMT)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:YVETTE
Last Name:GALLAIS
Suffix:
Gender:F
Credentials:LAT, ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 30TH AVE S APT 301
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7755
Mailing Address - Country:US
Mailing Address - Phone:701-630-2846
Mailing Address - Fax:
Practice Address - Street 1:1300 17TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-231-6378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDE3446979146N00000X
ND808-182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic