Healthcare Provider Details

I. General information

NPI: 1588019228
Provider Name (Legal Business Name): MAMMARIE KAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

IV. Provider business mailing address

1200 6TH AVE N
ST. CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone: 320-240-2206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4497
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4497
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4497
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: