Healthcare Provider Details

I. General information

NPI: 1104339399
Provider Name (Legal Business Name): KELSEY MARIE KIM NELSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21050 NEWBERRY AVE N
SCANDIA MN
55073-9103
US

IV. Provider business mailing address

21050 NEWBERRY AVE N
SCANDIA MN
55073-9103
US

V. Phone/Fax

Practice location:
  • Phone: 651-558-6259
  • Fax:
Mailing address:
  • Phone: 651-558-6259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2457026
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: