Healthcare Provider Details

I. General information

NPI: 1578992020
Provider Name (Legal Business Name): JOANNA KELLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 MINNESOTA AVE
DETROIT LAKES MN
56501-3035
US

IV. Provider business mailing address

712 MINNESOTA AVE
DETROIT LAKES MN
56501-3035
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-5628
  • Fax:
Mailing address:
  • Phone: 218-847-5628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR-185092-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: