Healthcare Provider Details

I. General information

NPI: 1134665334
Provider Name (Legal Business Name): KATHERINE VICHOREK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MAIN AVE S
PARK RAPIDS MN
56470-1550
US

IV. Provider business mailing address

4717 RIDGEWOOD DR
MOOSE LAKE MN
55767-9223
US

V. Phone/Fax

Practice location:
  • Phone: 509-222-1275
  • Fax:
Mailing address:
  • Phone: 651-303-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number54797
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number54797
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: