Basic Information
Provider Information | |||||||||
NPI: | 1114984028 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | KAYDEE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WICK | ||||||||
OtherFirstName: | KAYDEE | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6341 UNIVERSITY AVE NE | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554324946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635865844 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6341 UNIVERSITY AVE NE | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554324946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635865844 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 10/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2936 | MN | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | 1807 | WI | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.