Basic Information
| Provider Information | |||||||||
| NPI: | 1659469385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEES | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LRD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5501 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585065501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | 7013235709 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E INTERSTATE AVE STE C | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585031566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236400 | ||||||||
| FaxNumber: | 7013236401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 371 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 59578 | 05 | ND | MEDICAID |