Provider Demographics
NPI:1003040247
Name:THOMPSON, KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:327 13TH ST S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-9404
Mailing Address - Country:US
Mailing Address - Phone:763-972-3447
Mailing Address - Fax:763-972-3734
Practice Address - Street 1:327 13TH ST S
Practice Address - Street 2:SUITE 110
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-9404
Practice Address - Country:US
Practice Address - Phone:763-972-3447
Practice Address - Fax:763-972-3734
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5215111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor