Provider Demographics
NPI:1841649290
Name:GULLICKSRUD, KAITLEN (ATC/R)
Entity type:Individual
Prefix:
First Name:KAITLEN
Middle Name:
Last Name:GULLICKSRUD
Suffix:
Gender:F
Credentials:ATC/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 TRANSIT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3233
Mailing Address - Country:US
Mailing Address - Phone:715-379-0408
Mailing Address - Fax:
Practice Address - Street 1:1151 TRANSIT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3233
Practice Address - Country:US
Practice Address - Phone:715-379-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer