Healthcare Provider Details

I. General information

NPI: 1104641091
Provider Name (Legal Business Name): KILEY LAVANGER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

3553 GIRARD AVE S
MINNEAPOLIS MN
55408-3824
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-5000
  • Fax:
Mailing address:
  • Phone: 763-355-7781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12822
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: