Healthcare Provider Details

I. General information

NPI: 1831480607
Provider Name (Legal Business Name): CARISSA KUCALA AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-1478
  • Fax: 952-993-1250
Mailing address:
  • Phone: 952-993-1478
  • Fax: 952-993-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number8610
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: