Healthcare Provider Details

I. General information

NPI: 1992449151
Provider Name (Legal Business Name): KELLI JO ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 05/12/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 6TH ST SE
WILLMAR MN
56201-4675
US

IV. Provider business mailing address

1234 E HIGHWAY 7
MONTEVIDEO MN
56265-1705
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-4613
  • Fax: 855-625-7406
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9144
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: