Provider Demographics
NPI:1184135253
Name:MAGNUSON, KATELYN NICHOLE (RN)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:NICHOLE
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:NICHOLE
Other - Last Name:CROISSANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4672 W 20TH STREET RD UNIT 2224
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1555 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9117
Practice Address - Country:US
Practice Address - Phone:970-304-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1636216163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice