Healthcare Provider Details

I. General information

NPI: 1356816128
Provider Name (Legal Business Name): KORDAE JEWELL ANN HAYDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 03/03/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 9TH AVENUE SE, STE 2
WATFORD CITY ND
58854
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 701-842-4424
  • Fax:
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: