Provider Demographics
NPI:1316783210
Name:KACK, BRIANNA CORTNEY (RN)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:CORTNEY
Last Name:KACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:CORNTEY
Other - Last Name:APPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 17TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4835
Mailing Address - Country:US
Mailing Address - Phone:507-822-0530
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:507-822-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN243973-4163W00000X
NDR44279163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse