1568229698 NPI number — KRISTIN DOUCETTE APRN, PMHNP

Table of content: KRISTIN DOUCETTE APRN, PMHNP (NPI 1568229698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568229698 NPI number — KRISTIN DOUCETTE APRN, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUCETTE
Provider First Name:
KRISTIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAGLEY (MAIDEN NAME WAS FRIIS)
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568229698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13040 KINGWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAXTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56425-8382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-851-4102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 2ND ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56345-3559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-631-7000
Provider Business Practice Location Address Fax Number:
320-631-7229
Provider Enumeration Date:
03/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  11348 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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