Healthcare Provider Details

I. General information

NPI: 1790648350
Provider Name (Legal Business Name): BETHANY ANN KATKA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 17TH ST S
MOORHEAD MN
56560-5825
US

IV. Provider business mailing address

2306 17TH ST S
MOORHEAD MN
56560-5825
US

V. Phone/Fax

Practice location:
  • Phone: 843-214-3526
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: