Provider Demographics
NPI:1104184910
Name:THOMPSON, KELLI YVONNE
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:YVONNE
Last Name:THOMPSON
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 1:13 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1715
Mailing Address - Country:US
Mailing Address - Phone:218-429-0140
Mailing Address - Fax:
Practice Address - Street 1:13 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1715
Practice Address - Country:US
Practice Address - Phone:218-429-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1063186-1-FADS372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion