Healthcare Provider Details

I. General information

NPI: 1154935435
Provider Name (Legal Business Name): KELLY NICOLE RICKE MA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 EAGAN WOODS DR
EAGAN MN
55121-1138
US

IV. Provider business mailing address

2620 EAGAN WOODS DR
EAGAN MN
55121-1138
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5201
  • Fax:
Mailing address:
  • Phone: 651-968-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3429
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0543
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: