Healthcare Provider Details

I. General information

NPI: 1285605592
Provider Name (Legal Business Name): KELLY WINTER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRA CARE CIRCLE CENTRA CARE CLINIC WOMENS CHILDRENS
ST CLOUD MN
56303
US

IV. Provider business mailing address

1900 CENTRA CARE CIRCLE CENTRA CARE CLINIC WOMENS CHILDRENS
ST CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax:
Mailing address:
  • Phone: 320-654-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR128866-9
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR1288669
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: