Healthcare Provider Details

I. General information

NPI: 1801865084
Provider Name (Legal Business Name): TROY PATRICK KITTLESON GNP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST #290
BLOOMINGTON MN
55435-2111
US

IV. Provider business mailing address

10725 AQUILA AVE S
BLOOMINGTON MN
55438-2226
US

V. Phone/Fax

Practice location:
  • Phone: 952-836-3637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR1394980
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: