Provider Demographics
NPI:1184218208
Name:CUNNINGHAM, KELSEY JO (CNP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S STATE ST STE 113
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4502
Mailing Address - Country:US
Mailing Address - Phone:605-225-0378
Mailing Address - Fax:
Practice Address - Street 1:105 S STATE ST STE 113
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4502
Practice Address - Country:US
Practice Address - Phone:605-225-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001998363LF0000X
NDR49717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily