MEDICARE: KAYLA MARIE TACKMANN DPT

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	225100000X	Physical Therapist	11127	MN

General Provider Information

NPI Number	:	1700369790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA MARIE TACKMANN DPT

Provider Business Mailing Address
First Line	:	7825 3RD ST N STE 105
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-5403
Country	:	US
Telephone Number	:	952-835-4512
Fax Number	:	888-425-0398

Provider Business Practice Location Address
First Line	:	30 FAIRVIEW AVE S STE 200
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1463
Country	:	US
Telephone Number	:	952-835-4512
Fax Number	:	888-425-0398

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

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	04/10/2023

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