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General NPI Number Information
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NPI Number | 1780297218
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Entity Type | Individual
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Provider Name | KELLIE JEAN RUSCH APRN, CNP
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Gender | Female
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Dates
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Enumeration Date | 08/25/2020
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Last Update Date | 08/25/2020
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Provider Practice Location Address
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Address Line | 671 VANDALIA ST
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City | SAINT PAUL
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State | MN
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Zip | 55114-1312
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Country | US
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Telephone | 651-698-2406
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Fax |
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Provider Business Mailing Address
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Address Line | 4227 UPTON AVE N
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City | MINNEAPOLIS
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State | MN
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Zip | 55412-1523
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Country | US
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Telephone | 612-799-4660
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 1747508
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 6976
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License Number State | MN
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