Provider Demographics
NPI:1558747782
Name:NELSON, KIRBY MAE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KIRBY
Middle Name:MAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11334 86TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4528
Mailing Address - Country:US
Mailing Address - Phone:763-255-2125
Mailing Address - Fax:763-255-2126
Practice Address - Street 1:11334 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4528
Practice Address - Country:US
Practice Address - Phone:763-255-2125
Practice Address - Fax:763-255-2126
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505714NP-PP364SP0808X
OR201408830RN163W00000X
IAG147604363LP0808X
MN8205363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse