Healthcare Provider Details

I. General information

NPI: 1609323914
Provider Name (Legal Business Name): KAILYN JANIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 18 EAST
PINE RIDGE SD
57770
US

IV. Provider business mailing address

3117 SOLUTIONS CTR
CHICAGO IL
60677-3001
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-5131
  • Fax:
Mailing address:
  • Phone: 605-867-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR045877
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: