Basic Information
| Provider Information | |||||||||
| NPI: | 1053849026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WENDT | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | SUE | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055411140 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 MAPLE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558114521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182794209 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 1994 | SD | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | 10889 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.