Healthcare Provider Details

I. General information

NPI: 1831970599
Provider Name (Legal Business Name): KELLEY JEAN VIGSTOL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLEY JEAN WU

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 37TH AVE SW
MINOT ND
58701-7669
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-418-8342
  • Fax:
Mailing address:
  • Phone: 701-857-3517
  • Fax: 701-418-8621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number205980
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR47259
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: