Provider Demographics
NPI:1710655923
Name:REINEKE, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:REINEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 WOODWINDS DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2202
Mailing Address - Country:US
Mailing Address - Phone:651-326-1044
Mailing Address - Fax:
Practice Address - Street 1:1825 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2202
Practice Address - Country:US
Practice Address - Phone:320-287-0528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN207KA0200X207KA0200X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant