Healthcare Provider Details

I. General information

NPI: 1730093808
Provider Name (Legal Business Name): CHEYENNE KALISIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 13TH AVE E
WEST FARGO ND
58078-3328
US

IV. Provider business mailing address

3640 42ND ST S APT 110
FARGO ND
58104-7435
US

V. Phone/Fax

Practice location:
  • Phone: 701-277-8844
  • Fax:
Mailing address:
  • Phone: 701-277-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: