Provider Demographics
NPI:1376163477
Name:BLOMMER, KELSEY ANN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:BLOMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 ISANTI CT NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6107
Mailing Address - Country:US
Mailing Address - Phone:320-290-4438
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-9632
Practice Address - Country:US
Practice Address - Phone:763-497-6632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist