Healthcare Provider Details

I. General information

NPI: 1134107444
Provider Name (Legal Business Name): KIM KALLESTAD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 HIGHLAND BLVD SUITE 1200
BOZEMAN MT
59715-6900
US

IV. Provider business mailing address

925 HIGHLAND BLVD SUITE 1200
BOZEMAN MT
59715-6900
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-0704
  • Fax: 406-587-1147
Mailing address:
  • Phone: 406-587-0704
  • Fax: 406-587-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN15264
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: