Provider Demographics
NPI:1306523949
Name:FERNHOLZ, KYLEE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:FERNHOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 E GATEWAY CIR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3617
Mailing Address - Country:US
Mailing Address - Phone:320-815-0737
Mailing Address - Fax:
Practice Address - Street 1:9394 W DODGE RD STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3319
Practice Address - Country:US
Practice Address - Phone:320-815-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-04
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty