Provider Demographics
NPI:1417619602
Name:KJELLAND, MARTI JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:MARTI
Middle Name:JEAN
Last Name:KJELLAND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W MILTON RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-2805
Mailing Address - Country:US
Mailing Address - Phone:518-605-8792
Mailing Address - Fax:
Practice Address - Street 1:125 W MILTON RD
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-2805
Practice Address - Country:US
Practice Address - Phone:518-605-8792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282001-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse