Provider Demographics
NPI:1659532265
Name:KELLY-WILLIAMS, KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KELLY-WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W 66TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2109
Mailing Address - Country:US
Mailing Address - Phone:952-920-7200
Mailing Address - Fax:763-302-4234
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2111
Practice Address - Country:US
Practice Address - Phone:952-920-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70803207R00000X
WI13952084N0400X
MN553382084P0800X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNP01147437OtherMEDICARE RAILROAD
MNENROLLEDMedicaid
MN130001721Medicare PIN