Healthcare Provider Details

I. General information

NPI: 1972259505
Provider Name (Legal Business Name): JACQUELINE ANN KELLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE ANN TISHER

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 3RD ST NW
MOHALL ND
58761-4105
US

IV. Provider business mailing address

PO BOX 811
MOHALL ND
58761-0811
US

V. Phone/Fax

Practice location:
  • Phone: 306-540-7407
  • Fax:
Mailing address:
  • Phone: 306-540-7407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number33918
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: