Provider Demographics
NPI:1013452655
Name:CRANDALL, KIMBERLY (RN, BSN, CDE)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:RN, BSN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 32ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5800
Mailing Address - Country:US
Mailing Address - Phone:701-234-2245
Mailing Address - Fax:701-234-8717
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-2245
Practice Address - Fax:701-234-8717
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130719-7163WD0400X
NDR30152163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator