Provider Demographics
NPI:1346981131
Name:MCGRAW, KELLY RAE (MS, LN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:MCGRAW
Suffix:
Gender:F
Credentials:MS, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SNELLING AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6842
Mailing Address - Country:US
Mailing Address - Phone:651-699-3428
Mailing Address - Fax:651-695-0191
Practice Address - Street 1:123 VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:NORTH OAKS
Practice Address - State:MN
Practice Address - Zip Code:55127-3007
Practice Address - Country:US
Practice Address - Phone:651-773-0000
Practice Address - Fax:651-695-0191
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN183133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist