Healthcare Provider Details

I. General information

NPI: 1861307332
Provider Name (Legal Business Name): KAYLA WENTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2021 2ND ST
LAKE PARK MN
56554-4000
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone: 701-367-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR44648
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: