Healthcare Provider Details

I. General information

NPI: 1699686741
Provider Name (Legal Business Name): LAUREN KELLY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 MAIN ST NE
MINNEAPOLIS MN
55413-1931
US

IV. Provider business mailing address

19 CENTRAL AVE
BUFFALO MN
55313-1569
US

V. Phone/Fax

Practice location:
  • Phone: 612-362-2415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number107721
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: