Healthcare Provider Details

I. General information

NPI: 1336709203
Provider Name (Legal Business Name): AMY MARIE DOLAN L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY MARIE KAISER L.AC

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 N POKEGAMA AVE STE 100
GRAND RAPIDS MN
55744-2745
US

IV. Provider business mailing address

304 N POKEGAMA AVE STE 100
GRAND RAPIDS MN
55744-2745
US

V. Phone/Fax

Practice location:
  • Phone: 218-398-0550
  • Fax:
Mailing address:
  • Phone: 218-398-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1519
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: