MEDICARE: MISS JADE ALEXIS KELLING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F08220262	ND
2	363LF0000X	Family Nurse Practitioner	R43520	ND
3	363LF0000X	Family Nurse Practitioner	F08220262	ND

General Provider Information

NPI Number	:	1366179509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JADE ALEXIS KELLING

Provider Business Mailing Address
First Line	:	PO BOX 1256
Second Line	:
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-1256
Country	:	US
Telephone Number	:	701-444-2888
Fax Number	:	701-444-2813

Provider Business Practice Location Address
First Line	:	340 N MAIN ST STE 311
Second Line	:
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-7308
Country	:	US
Telephone Number	:	701-444-2888
Fax Number	:	701-444-2813

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2022
Last Update Date	:	03/08/2023

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