Provider Demographics
NPI:1386398139
Name:UDOVICH, KATHLEEN (APRN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:UDOVICH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 E HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1445
Mailing Address - Country:US
Mailing Address - Phone:218-235-1108
Mailing Address - Fax:
Practice Address - Street 1:624 13TH ST S
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-3149
Practice Address - Country:US
Practice Address - Phone:218-749-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9004363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health