Healthcare Provider Details

I. General information

NPI: 1548383664
Provider Name (Legal Business Name): IMO I KALLA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 CONNECTICUT AVENUE S HP CENTRAL MN CLINICS
SARTELL MN
56377-2486
US

IV. Provider business mailing address

8170 33RD AVE S MS21110Q
FREEPORT MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5220
  • Fax: 320-203-2113
Mailing address:
  • Phone: 952-883-5375
  • Fax: 320-203-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR118728-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: