Provider Demographics
NPI:1912679655
Name:KVIDAHL, SHARI LYNN (BSN-RN)
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:LYNN
Last Name:KVIDAHL
Suffix:
Gender:F
Credentials:BSN-RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 GRANDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2221
Mailing Address - Country:US
Mailing Address - Phone:319-777-4311
Mailing Address - Fax:
Practice Address - Street 1:1615 GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2221
Practice Address - Country:US
Practice Address - Phone:319-777-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA143111163WI0500X, 163WW0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA143111OtherCOMPACT NURSING LICENSE NUMBER