Provider Demographics
NPI:1497461990
Name:NORMAN, KELLY RAE (CNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:NORMAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RAE
Other - Last Name:NORTHWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1355 190TH AVE
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-9079
Mailing Address - Country:US
Mailing Address - Phone:320-828-2343
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-252-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302580101YA0400X
MN9891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)