Healthcare Provider Details

I. General information

NPI: 1750057428
Provider Name (Legal Business Name): KELSEA JAYE RUSH CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 08/21/2021
Certification Date: 08/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7920 OLD CEDAR AVE S
BLOOMINGTON MN
55425-1207
US

IV. Provider business mailing address

22230 MURRAY ST
EXCELSIOR MN
55331-3110
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-1800
  • Fax:
Mailing address:
  • Phone: 952-715-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number474
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: