Healthcare Provider Details

I. General information

NPI: 1245984095
Provider Name (Legal Business Name): KELLY JO GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 INDUSTRIAL DR NW
ROCHESTER MN
55901-0700
US

IV. Provider business mailing address

807 E COUNTY RD N
LE ROY MN
55951-1283
US

V. Phone/Fax

Practice location:
  • Phone: 507-322-7750
  • Fax: 507-517-3055
Mailing address:
  • Phone: 507-589-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: