Healthcare Provider Details

I. General information

NPI: 1609384973
Provider Name (Legal Business Name): KATHERINE WAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13980 NORTHDALE BLVD
ROGERS MN
55374
US

IV. Provider business mailing address

13980 NORTHDALE BLVD
ROGERS MN
55374-2147
US

V. Phone/Fax

Practice location:
  • Phone: 763-428-1920
  • Fax: 612-874-2916
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2230470
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number6045
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: