Healthcare Provider Details

I. General information

NPI: 1073880464
Provider Name (Legal Business Name): KAYLA MAE CARLSON RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA MAE KRAGH RD, LD

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR SUITE 2500
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR SUITE 2500
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-5000
  • Fax: 218-828-7579
Mailing address:
  • Phone: 320-229-5000
  • Fax: 218-828-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3066
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1058649
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: