Healthcare Provider Details

I. General information

NPI: 1861374449
Provider Name (Legal Business Name): KELSEY MARBEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 INDEPENDENCE DR
MANKATO MN
56001-7767
US

IV. Provider business mailing address

329 TANAGER PATH
MANKATO MN
56001-6396
US

V. Phone/Fax

Practice location:
  • Phone: 507-387-3249
  • Fax:
Mailing address:
  • Phone: 507-995-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT185
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: