Healthcare Provider Details

I. General information

NPI: 1710635198
Provider Name (Legal Business Name): KAITLEN KAROLINA LEE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLEN KAROLINA UECKER

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 119TH AVE SE
VALLEY CITY ND
58072-9405
US

IV. Provider business mailing address

340 9TH ST NW
VALLEY CITY ND
58072-2125
US

V. Phone/Fax

Practice location:
  • Phone: 701-840-4630
  • Fax:
Mailing address:
  • Phone: 701-840-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR47841
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberR47841
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: