Provider Demographics
NPI:1083212625
Name:FERREIRA, KELE
Entity Type:Individual
Prefix:
First Name:KELE
Middle Name:
Last Name:FERREIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 S WASHINGTON ST STE G
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-8155
Mailing Address - Country:US
Mailing Address - Phone:701-205-3000
Mailing Address - Fax:701-732-2501
Practice Address - Street 1:4700 S WASHINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-8155
Practice Address - Country:US
Practice Address - Phone:701-205-3000
Practice Address - Fax:701-732-2501
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14228363A00000X
FLPA9113712363AM0700X
PAMA061930363AM0700X
NDPAC0974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical