Healthcare Provider Details

I. General information

NPI: 1851227979
Provider Name (Legal Business Name): KAYLEE BROOKE CONDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEE BROOKE KRAY

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 COUNTY ROAD 120
SAINT CLOUD MN
56303-4879
US

IV. Provider business mailing address

21 COUNTY ROAD 120
SAINT CLOUD MN
56303-4879
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-5880
  • Fax: 320-253-5393
Mailing address:
  • Phone: 320-259-5880
  • Fax: 320-253-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number270727
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: