=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104600394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLAN ANN MUTHYALA DNP, APRN, FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2023
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 HUNDERTMARK RD
-----------------------------------------------------
City | CHASKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55318-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-361-2450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 HUNDERTMARK RD
-----------------------------------------------------
City | CHASKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55318-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-361-2450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F08230671
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11665
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------