Healthcare Provider Details

I. General information

NPI: 1083969398
Provider Name (Legal Business Name): KELLY RAE HEBL GARCIA CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 W HIGHWAY 61
WINONA MN
55987-1957
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 507-615-0600
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number713373
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number6002
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: