Provider Demographics
NPI:1063485514
Name:BOIE, KELLY ANN (PPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BOIE
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:OVERBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14001 RIDGEDALE DR, STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1781
Mailing Address - Country:US
Mailing Address - Phone:952-473-0211
Mailing Address - Fax:952-473-7908
Practice Address - Street 1:14001 RIDGEDALE DR, STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1781
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:952-473-7908
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1121373163WP0200X
MNCNP0812363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731306300Medicaid
P15214Medicare UPIN
MN731306300Medicaid