Healthcare Provider Details

I. General information

NPI: 1104432079
Provider Name (Legal Business Name): KELLY ROGERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 2ND ST NE
NEW PRAGUE MN
56071-1709
US

IV. Provider business mailing address

301 2ND ST NE
NEW PRAGUE MN
56071-1709
US

V. Phone/Fax

Practice location:
  • Phone: 952-758-4431
  • Fax: 763-450-3986
Mailing address:
  • Phone: 952-758-4431
  • Fax: 612-488-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2517
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: