MEDICARE: KASSANDRA FAYE HOOTEN CNA, CVI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant		ND

General Provider Information

NPI Number	:	1114621026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSANDRA FAYE HOOTEN CNA, CVI

Provider Business Mailing Address
First Line	:	3433 15TH ST S
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-6928
Country	:	US
Telephone Number	:	701-429-7593
Fax Number	:

Provider Business Practice Location Address
First Line	:	5518 SUNFLOWER LN S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-3962
Country	:	US
Telephone Number	:	701-429-7593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	03/27/2023

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