Healthcare Provider Details

I. General information

NPI: 1225348352
Provider Name (Legal Business Name): MARK OLIVER KRAGENBRING RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 SHADY OAKS RD
ATWATER MN
56209-9365
US

IV. Provider business mailing address

5501 SHADY OAKS RD
ATWATER MN
56209-9365
US

V. Phone/Fax

Practice location:
  • Phone: 320-974-8266
  • Fax:
Mailing address:
  • Phone: 320-974-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1279678
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberR1279678
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: