Provider Demographics
NPI:1619272572
Name:KELLEY, JENELLE PHILIPCZYK (PA-C)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:PHILIPCZYK
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:MARIE
Other - Last Name:PHILIPCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1055 WESTGATE DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1065
Mailing Address - Country:US
Mailing Address - Phone:651-312-1505
Mailing Address - Fax:651-641-1720
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:SUITE 212
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:651-312-1700
Practice Address - Fax:952-920-4148
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1525363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical