MEDICARE: KAITLEN KAROLINA LEE REGISTERED NURSE

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	163WH0200X	Home Health Registered Nurse	R47841	ND
2	251J00000X	Nursing Care Agency
3	253Z00000X	In Home Supportive Care Agency
4	3747P1801X	Personal Care Attendant	R47841	ND

General Provider Information

NPI Number	:	1710635198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLEN KAROLINA LEE REGISTERED NURSE

Provider Business Mailing Address
First Line	:	340 9TH ST NW
Second Line	:
City	:	VALLEY CITY
State	:	ND
Zip	:	58072-2125
Country	:	US
Telephone Number	:	701-840-4630
Fax Number	:

Provider Business Practice Location Address
First Line	:	3362 119TH AVE SE
Second Line	:
City	:	VALLEY CITY
State	:	ND
Zip	:	58072-9405
Country	:	US
Telephone Number	:	701-840-4630
Fax Number	:

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

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	03/14/2022

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