Provider Demographics
NPI:1912221854
Name:KJELLERSON, MICHAEL CRAIG (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CRAIG
Last Name:KJELLERSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 18TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4627
Mailing Address - Country:US
Mailing Address - Phone:701-730-2030
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY DR N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58105-2502
Practice Address - Country:US
Practice Address - Phone:701-730-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND329-072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer