Healthcare Provider Details

I. General information

NPI: 1770934580
Provider Name (Legal Business Name): EMILY KOLOC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 RAILROAD ST E
NORWOOD YOUNG AMERICA MN
55368-4500
US

IV. Provider business mailing address

124 RAILROAD ST E
NORWOOD YOUNG AMERICA MN
55368-4500
US

V. Phone/Fax

Practice location:
  • Phone: 952-457-2720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 236538-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: