Provider Demographics
NPI:1891393278
Name:DANIELSON, KELLI J (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3768 124TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-1637
Mailing Address - Country:US
Mailing Address - Phone:920-606-4783
Mailing Address - Fax:
Practice Address - Street 1:1200 SHINGLE CREEK XING
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2835
Practice Address - Country:US
Practice Address - Phone:763-354-1948
Practice Address - Fax:763-354-1942
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist