Provider Demographics
NPI:1255304762
Name:KYLE, KELLI MARIE (MS, PA-C, ATC)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:MARIE
Last Name:KYLE
Suffix:
Gender:F
Credentials:MS, PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 1ST DR NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST DRIVE NW
Practice Address - Street 2:MAYO CLINIC HEALTH SYSTEM
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960017262255A2300X
MN16122255A2300X
MN11841363A00000X, 363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant