Healthcare Provider Details

I. General information

NPI: 1275446882
Provider Name (Legal Business Name): KAELYN TALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 PHEASANT RUN AVE
DICKINSON ND
58601-6536
US

IV. Provider business mailing address

870 PHEASANT RUN AVE
DICKINSON ND
58601-6536
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-3899
  • Fax:
Mailing address:
  • Phone: 701-483-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2334
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: