Healthcare Provider Details

I. General information

NPI: 1346607587
Provider Name (Legal Business Name): KIMBERLY R NEELY AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 05/16/2025
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALTRU CANCER CENTER 960 S. COLUMBIA ROAD
GRAND FORKS ND
58201-4036
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax: 304-781-5139
Mailing address:
  • Phone: 701-780-1891
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201611
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number83344
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number201611
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number201611
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: