Healthcare Provider Details

I. General information

NPI: 1902813652
Provider Name (Legal Business Name): MARY ELIZABETH KELLY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/01/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER ROAD
KYLE SD
57752
US

IV. Provider business mailing address

1213 1/2 QUINCY ST
RAPID CITY SD
57701
US

V. Phone/Fax

Practice location:
  • Phone: 605-455-8219
  • Fax: 605-455-1481
Mailing address:
  • Phone: 605-415-8283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCM000024
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: