Provider Demographics
NPI:1285043547
Name:HANSON, KELLIE (DNP PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:DNP PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 86TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4510
Mailing Address - Country:US
Mailing Address - Phone:763-400-7825
Mailing Address - Fax:
Practice Address - Street 1:4958 SCOTTS CREEK TRL
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30096-2963
Practice Address - Country:US
Practice Address - Phone:678-510-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2335469163WP0808X
GARN238773163WP0808X
MN10047363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health