Provider Demographics
NPI:1972132249
Name:WYSUPH, KALEE IRENE (APRN,CNP)
Entity type:Individual
Prefix:
First Name:KALEE
Middle Name:IRENE
Last Name:WYSUPH
Suffix:
Gender:F
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:KALEE
Other - Middle Name:IRENE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:SSB-6
Mailing Address - Street 2:400 E 3RD ST
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NDR42839363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program