Healthcare Provider Details

I. General information

NPI: 1013478775
Provider Name (Legal Business Name): KELLY JEAN KILLIAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WASHINGTON AVE N FL 2
MINNEAPOLIS MN
55401-2503
US

IV. Provider business mailing address

121 WASHINGTON AVE N FL 2
MINNEAPOLIS MN
55401-2503
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number7373
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number0024177448
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR262947
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number500013722
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: