Provider Demographics
NPI:1366914996
Name:TEPOEL, KALLIE JO (MS, BSN, CRNA)
Entity type:Individual
Prefix:MRS
First Name:KALLIE
Middle Name:JO
Last Name:TEPOEL
Suffix:
Gender:F
Credentials:MS, BSN, CRNA
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:JO
Other - Last Name:AGRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38548 OASIS RD
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9637
Mailing Address - Country:US
Mailing Address - Phone:651-235-3131
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-697-5804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2280367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered