Healthcare Provider Details

I. General information

NPI: 1033504071
Provider Name (Legal Business Name): KIRSTEN MA INDRELIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST
DULUTH MN
55805-1951
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax: 504-988-1846
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number65590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: