Provider Demographics
NPI:1588645121
Name:KELLY, AMY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2247 SARGENT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1157
Mailing Address - Country:US
Mailing Address - Phone:651-699-9555
Mailing Address - Fax:
Practice Address - Street 1:2004 RANDOLPH AVE
Practice Address - Street 2:#4112
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1750
Practice Address - Country:US
Practice Address - Phone:651-690-6714
Practice Address - Fax:651-690-6188
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN407272080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG86162Medicare UPIN