MEDICARE: KAYLA MARIE HENNUM

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	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123456	OTHER	ND	ATHLETIC TRAINING

General Provider Information

NPI Number	:	1215493374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA MARIE HENNUM

Provider Business Mailing Address
First Line	:	1225 2ND ST N
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58102-2722
Country	:	US
Telephone Number	:	218-766-8475
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 2ND ST N
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58102-2722
Country	:	US
Telephone Number	:	218-766-8475
Fax Number	:

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

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	02/13/2019

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Directions to “ KAYLA MARIE HENNUM ” Practice Location

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