Provider Demographics
NPI:1215211750
Name:HERRICK, KELSEY R (LRD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:R
Last Name:HERRICK
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:R
Other - Last Name:BRATLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-2484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4939
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-2345
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND847133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55920Medicaid
NDN717231Medicare PIN
NDN717228Medicare PIN