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General NPI Number Information
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NPI Number | 1316504467
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Entity Type | Individual
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Provider Name | KAYLEE DIRCKS
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Gender | Female
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 05/23/2019
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Provider Practice Location Address
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Address Line | 12545 320 1/2 AVE NW
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City | PRINCETON
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State | MN
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Zip | 55371-4744
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Country | US
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Telephone | 612-804-7212
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Fax |
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Provider Business Mailing Address
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Address Line | 12208 313TH AVE
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City | PRINCETON
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State | MN
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Zip | 55371-3320
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Country | US
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Telephone | 612-804-7212
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State | MN
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