Provider Demographics
NPI:1629668462
Name:DICKE, KELLY JOHANNA (APRN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JOHANNA
Last Name:DICKE
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JOHANNA
Other - Last Name:HUNEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2355 HWY 36 W.
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HWY 36 W.
Practice Address - Street 2:STE. 100
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7905363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily