Healthcare Provider Details

I. General information

NPI: 1518071695
Provider Name (Legal Business Name): KATHLEEN ANN FAGERLUND CRNA, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR # 112A
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1880 NEWBERRY AVE N
STILLWATER MN
55082-1705
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-3392
  • Fax: 612-467-5887
Mailing address:
  • Phone: 612-467-3392
  • Fax: 612-467-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR104796-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: