Healthcare Provider Details

I. General information

NPI: 1104184910
Provider Name (Legal Business Name): MS. KELLI YVONNE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 4TH AVE SE
AITKIN MN
56431-1715
US

IV. Provider business mailing address

13 4TH AVE SE
AITKIN MN
56431-1715
US

V. Phone/Fax

Practice location:
  • Phone: 218-429-0140
  • Fax:
Mailing address:
  • Phone: 218-429-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number1063186-1-FADS
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: