Healthcare Provider Details

I. General information

NPI: 1558510693
Provider Name (Legal Business Name): KIM LACEY FELLOWS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM LACEY WILKERSON NP-C

II. Dates (important events)

Enumeration Date: 09/13/2008
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 507-369-5314
  • Fax:
Mailing address:
  • Phone: 507-373-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA124361
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12287-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 189805-9
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number456
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: