Provider Demographics
NPI:1992457717
Name:KIDD, JOHN (CNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:KIDD
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6237 RIVLYN AVE NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4538
Mailing Address - Country:US
Mailing Address - Phone:612-412-4661
Mailing Address - Fax:
Practice Address - Street 1:6237 RIVLYN AVE NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-4538
Practice Address - Country:US
Practice Address - Phone:612-412-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10761063374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide