Healthcare Provider Details

I. General information

NPI: 1275298366
Provider Name (Legal Business Name): MICHELLE KUDRNA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 W INTERSTATE AVE
BISMARCK ND
58503-0936
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-5437
  • Fax:
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1191
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: