Healthcare Provider Details

I. General information

NPI: 1215470943
Provider Name (Legal Business Name): KAITLYN LATOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

3500 COUNTY ROAD 39 NW
MAPLE LAKE MN
55358-3019
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax:
Mailing address:
  • Phone: 320-333-2804
  • Fax: 320-243-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number121829
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: