Provider Demographics
NPI:1811079163
Name:FEHLBERG, KAEDI RAE (FNP)
Entity type:Individual
Prefix:
First Name:KAEDI
Middle Name:RAE
Last Name:FEHLBERG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 FREEPORT AVE NW
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2723
Mailing Address - Country:US
Mailing Address - Phone:763-581-5200
Mailing Address - Fax:763-581-5201
Practice Address - Street 1:800 FREEPORT AVE NW
Practice Address - Street 2:SUITE 100A
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2723
Practice Address - Country:US
Practice Address - Phone:763-581-5200
Practice Address - Fax:763-581-5201
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540987163W00000X
NY430263363LA2100X
NY334565363LF0000X
MNR 199218-8363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500007100Medicare PIN