Healthcare Provider Details

I. General information

NPI: 1336186048
Provider Name (Legal Business Name): KELLI J SIMMONS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE STREET SOUTHEAST MAYO MAIL CODE 450
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

1570 EUSTIS ST APARTMENT 133
LAUDERDALE MN
55108-1260
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-5919
  • Fax: 612-625-4406
Mailing address:
  • Phone: 651-646-0172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberR183718-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number093545
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: