Provider Demographics
NPI:1023850740
Name:ANDERSON, KYLEE BREANNE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:BREANNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 LYNCH ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55307-2071
Mailing Address - Country:US
Mailing Address - Phone:320-510-5377
Mailing Address - Fax:
Practice Address - Street 1:622 ABERDEEN AVE
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-9516
Practice Address - Country:US
Practice Address - Phone:952-492-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202857224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant