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General NPI Number Information
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NPI Number | 1154754885
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Entity Type | Organization
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Legal Business Name | KAYA HEALTH CARE L.L.C.
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Dates
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Enumeration Date | 08/16/2013
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 26813 13TH AVE. S.E.
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City | SAINT CLOUD
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State | MN
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Zip | 56304-8536
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Country | US
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Telephone | 320-420-0268
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Fax |
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Provider Business Mailing Address
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Address Line | 26813 13TH AVE. S.E.
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City | SAINT CLOUD
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State | MN
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Zip | 56304-8536
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Country | US
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Telephone | 320-420-0268
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | ICEPHINE JOHNSON
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Credential | CNP BC
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Telephone | 320-420-0268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 682820800022
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License Number State | MN
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