Healthcare Provider Details

I. General information

NPI: 1689959777
Provider Name (Legal Business Name): LANCE KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

425 PINE RIDGE BLVD SUITE 211
WAUSAU WI
54401-4123
US

V. Phone/Fax

Practice location:
  • Phone: 865-342-8900
  • Fax:
Mailing address:
  • Phone: 715-845-5505
  • Fax: 715-848-2884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number169078-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1911
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: