Provider Demographics
NPI:1861125783
Name:HULTERSTRUM, KAYLA JO (PTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:JO
Last Name:HULTERSTRUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:KAYLA
Other - Middle Name:JO
Other - Last Name:HULTERSTRUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:28 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-1304
Mailing Address - Country:US
Mailing Address - Phone:320-262-2576
Mailing Address - Fax:
Practice Address - Street 1:612 S SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-3340
Practice Address - Country:US
Practice Address - Phone:320-693-4528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant