Provider Demographics
NPI:1093976540
Name:HENNINGSON-KAYE, KELSEY MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:MARIE
Last Name:HENNINGSON-KAYE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:HENNINGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 EASTVOLD AVE
Mailing Address - Street 2:ORTONVILLE AREA HEALTH SERVICES/NORTHSIDE MEDICAL CLINI
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278
Mailing Address - Country:US
Mailing Address - Phone:320-839-6157
Mailing Address - Fax:320-839-3851
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:ORTONVILLE AREA HEALTH SERVICES/NORTHSIDE MEDICAL CLINI
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1252
Practice Address - Country:US
Practice Address - Phone:320-839-6157
Practice Address - Fax:320-839-3851
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2260-023363AM0700X
MN10580363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093976540Medicaid
MN1093976540OtherMEDICA
MN1093976540OtherBCBS
MN1093976540OtherCHAMPUS
MN1093976540OtherRR MEDICARE
1093976540OtherDAKOTA CARE
MN1093976540OtherPREFERRED ONE
1093976540OtherUCARE
MN1093976540OtherPRIMEWEST HEALTH
1093976540OtherHEALTHPARTNERS