Provider Demographics
NPI:1487242764
Name:WALLSKOG, KATHRYN (DC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WALLSKOG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 W STATE ROUTE 89A STE B1
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5259
Mailing Address - Country:US
Mailing Address - Phone:928-862-4333
Mailing Address - Fax:928-862-4334
Practice Address - Street 1:2530 W STATE ROUTE 89A STE B1
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5259
Practice Address - Country:US
Practice Address - Phone:612-803-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6806111N00000X
AZ9147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor