Healthcare Provider Details

I. General information

NPI: 1417637331
Provider Name (Legal Business Name): CASSANDRA RACHELLE REPONEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 JARVINEN RD
CLOQUET MN
55720-3332
US

IV. Provider business mailing address

2970 JARVINEN RD
CLOQUET MN
55720-3332
US

V. Phone/Fax

Practice location:
  • Phone: 218-940-2187
  • Fax:
Mailing address:
  • Phone: 218-940-2187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2487749
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: