Provider Demographics
NPI:1316574478
Name:MARSHALL, KAITLYN JO (OD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JO
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7789 147TH ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7568
Mailing Address - Country:US
Mailing Address - Phone:952-432-0680
Mailing Address - Fax:952-432-8823
Practice Address - Street 1:7789 147TH ST W
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7568
Practice Address - Country:US
Practice Address - Phone:952-432-0680
Practice Address - Fax:952-432-8823
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist