Healthcare Provider Details

I. General information

NPI: 1992469191
Provider Name (Legal Business Name): KELLY MAE METZ NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

3802 132ND ST SW
PILLAGER MN
56473-2283
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax: 218-894-8403
Mailing address:
  • Phone: 218-831-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8677
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: