Provider Demographics
NPI:1609212703
Name:FERN, KELSEY M (LSW)
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:M
Last Name:FERN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1995
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-1995
Mailing Address - Country:US
Mailing Address - Phone:701-255-2773
Mailing Address - Fax:701-255-6261
Practice Address - Street 1:320 S 14TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6049
Practice Address - Country:US
Practice Address - Phone:701-223-0751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4765171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND74197Medicaid