MEDICARE: SUZANNE KELLY CNP

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	363LF0000X	Family Nurse Practitioner	R 147009-5	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R 147009-5	OTHER	MN	NURSING LICENSE

General Provider Information

NPI Number	:	1811300742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE KELLY CNP

Provider Business Mailing Address
First Line	:	218 MAIN ST
Second Line	:
City	:	COLD SPRING
State	:	MN
Zip	:	56320-2533
Country	:	US
Telephone Number	:	320-685-3020
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 MAIN ST
Second Line	:
City	:	COLD SPRING
State	:	MN
Zip	:	56320-2533
Country	:	US
Telephone Number	:	320-685-3020
Fax Number	:

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

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/16/2014

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