Provider Demographics
NPI:1891222709
Name:KIELSA, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:KIELSA
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 1:8280 MARKET BLVD APT 3105
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4400
Mailing Address - Country:US
Mailing Address - Phone:320-293-7783
Mailing Address - Fax:
Practice Address - Street 1:15 8TH AVE N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7670
Practice Address - Country:US
Practice Address - Phone:952-933-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4669225100000X
MN7809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1275666000Medicaid