MEDICARE: TAMARA LEA KITTLESON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	6765	MN

General Provider Information

NPI Number	:	1194379214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA LEA KITTLESON

Provider Business Mailing Address
First Line	:	5520 ALDRICH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1734
Country	:	US
Telephone Number	:	612-327-0803
Fax Number	:

Provider Business Practice Location Address
First Line	:	6600 FRANCE AVE S STE 415
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1804
Country	:	US
Telephone Number	:	952-303-6832
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2019
Last Update Date	:	07/26/2019

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