Provider Demographics
NPI:1962800995
Name:REILLY, NATASHA-KRISTIN
Entity type:Individual
Prefix:
First Name:NATASHA-KRISTIN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 PONTIAC LN
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9447
Mailing Address - Country:US
Mailing Address - Phone:952-239-1307
Mailing Address - Fax:
Practice Address - Street 1:910 PONTIAC LN
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9447
Practice Address - Country:US
Practice Address - Phone:952-239-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11222218174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN