MEDICARE: KAITLEN IRENE BRENNAN LAC

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	171100000X	Acupuncturist	1790	MN

General Provider Information

NPI Number	:	1922542661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLEN IRENE BRENNAN LAC

Provider Business Mailing Address
First Line	:	1053 FAIRMOUNT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-3123
Country	:	US
Telephone Number	:	651-206-8005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1032 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-3064
Country	:	US
Telephone Number	:	651-227-6865
Fax Number	:

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

Provider Enumeration Date	:	12/15/2016
Last Update Date	:	12/15/2016

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