Provider Demographics
NPI:1134566136
Name:NORDMEYER, KASSONDRA JO (ATC)
Entity type:Individual
Prefix:
First Name:KASSONDRA
Middle Name:JO
Last Name:NORDMEYER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1350
Mailing Address - Country:US
Mailing Address - Phone:612-330-1108
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:55454-1350
Practice Address - Country:US
Practice Address - Phone:612-330-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2255OtherSTATE OF MINNESOTA BOARD OF MEDICAL PRACTICE