Provider Demographics
NPI:1285855155
Name:HEFTI, KELLY S
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:HEFTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:HOFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-4539
Mailing Address - Fax:
Practice Address - Street 1:900 E 54TH ST
Practice Address - Street 2:STE 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104
Practice Address - Country:US
Practice Address - Phone:605-328-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR025508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS101745Medicare PIN