Provider Demographics
NPI:1427699628
Name:WALL, KATHERINE RACHEL (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:RACHEL
Last Name:WALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:RACHEL
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1838
Mailing Address - Country:US
Mailing Address - Phone:585-489-4304
Mailing Address - Fax:
Practice Address - Street 1:1200 LAGOON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2077
Practice Address - Country:US
Practice Address - Phone:612-823-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95058339163W00000X
MN9958363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3094Medicaid