=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629897160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY JEAN GROSSMAN CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2303 WYCLIFF ST STE W210
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55114-1272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-424-0434
-----------------------------------------------------
Fax | 877-905-7069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6204 CASCADE PASS
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-645-7599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 12166
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------