Healthcare Provider Details

I. General information

NPI: 1295135515
Provider Name (Legal Business Name): MICHAEL KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10112 STEVENS AVE S
BLOOMINGTON MN
55420-4934
US

IV. Provider business mailing address

10112 STEVENS AVE S
BLOOMINGTON MN
55420-4934
US

V. Phone/Fax

Practice location:
  • Phone: 612-990-8151
  • Fax:
Mailing address:
  • Phone: 612-990-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: