MEDICARE: KANIKA LANESE BAKER

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	335E00000X	Prosthetic/Orthotic Supplier	18438613	MN

General Provider Information

NPI Number	:	1619578648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANIKA LANESE BAKER

Provider Business Mailing Address
First Line	:	12526 74TH AVE N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-5290
Country	:	US
Telephone Number	:	612-458-7857
Fax Number	:

Provider Business Practice Location Address
First Line	:	7240 BROOKLYN BLVD STE 150
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55429-1274
Country	:	US
Telephone Number	:	888-507-6235
Fax Number	:

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

Provider Enumeration Date	:	11/05/2020
Last Update Date	:	11/05/2020

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Directions to “ KANIKA LANESE BAKER ” Practice Location

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