Provider Demographics
NPI:1235167503
Name:KELLY, LORI L (RN, CNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 HAMLINE AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-631-6100
Mailing Address - Fax:651-631-6343
Practice Address - Street 1:2845 HAMLINE AVE NORTH
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-631-6100
Practice Address - Fax:651-631-6343
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1533479363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN474957000Medicaid
Q53462Medicare UPIN