Healthcare Provider Details

I. General information

NPI: 1356513212
Provider Name (Legal Business Name): SHANNON KILICHOWSKI LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

IV. Provider business mailing address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax: 218-333-5360
Mailing address:
  • Phone: 218-333-5000
  • Fax: 218-333-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: