Provider Demographics
NPI:1104470061
Name:REDDICK, KAILEY ANNAMAE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:ANNAMAE
Last Name:REDDICK
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 E BELTLINE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-6003
Mailing Address - Country:US
Mailing Address - Phone:218-263-3880
Mailing Address - Fax:218-263-8411
Practice Address - Street 1:3429 E BELTLINE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-6003
Practice Address - Country:US
Practice Address - Phone:218-263-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer