Basic Information
| Provider Information | |||||||||
| NPI: | 1710988043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLOGG | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2276 118TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554495443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512458705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9220 BASS LAKE RD | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | NEW HOPE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554283000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330363 | ||||||||
| FaxNumber: | 7635330842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 102438 | MN | Y | Other Service Providers | Specialist |
No ID Information.