Healthcare Provider Details

I. General information

NPI: 1780998088
Provider Name (Legal Business Name): MICHELLE KETT ABBOTT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 08/06/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-2522
US

IV. Provider business mailing address

110 CRAIG PLACE
WILLERNIE MN
55090
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-6000
  • Fax:
Mailing address:
  • Phone: 919-684-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number084248
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number084248
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: