Healthcare Provider Details

I. General information

NPI: 1245101096
Provider Name (Legal Business Name): KALLIE ESPELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 23RD AVE S
FARGO ND
58104-7927
US

IV. Provider business mailing address

5455 33RD AVE S APT 308
FARGO ND
58104-7706
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-2976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR48079
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: