Basic Information
| Provider Information | |||||||||
| NPI: | 1831149046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULENTICH | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D./F.A.C.O.G. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 1ST ST S | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187416221 | ||||||||
| FaxNumber: | 2187412550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 19781 | MN | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 29304SU | 01 | MN | BCBS | OTHER |