Provider Demographics
NPI:1013762178
Name:VETTLESON, KASSANDRA (PHARMD)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:VETTLESON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 11TH ST W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3602
Practice Address - Country:US
Practice Address - Phone:701-234-3642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRRPH62591835P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0200XPharmacy Service ProvidersPharmacistPediatrics