Provider Demographics
NPI:1790799260
Name:KNEWTSON, KELLY MELISSA (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MELISSA
Last Name:KNEWTSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23505 SMITHTOWN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-4541
Mailing Address - Country:US
Mailing Address - Phone:952-470-8555
Mailing Address - Fax:952-401-8785
Practice Address - Street 1:23505 SMITHTOWN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-4541
Practice Address - Country:US
Practice Address - Phone:952-470-8555
Practice Address - Fax:952-401-8785
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410065400Medicaid
U80033Medicare UPIN
MN410065400Medicaid