Provider Demographics
NPI:1912358219
Name:CANNATA, KELLI MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MICHELLE
Last Name:CANNATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MICHELLE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8290 UNIVERSITY AVE NE
Mailing Address - Street 2:STE 200
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1847
Mailing Address - Country:US
Mailing Address - Phone:763-786-9543
Mailing Address - Fax:763-786-3320
Practice Address - Street 1:8290 UNIVERSITY AVE NE
Practice Address - Street 2:STE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1847
Practice Address - Country:US
Practice Address - Phone:763-786-9543
Practice Address - Fax:763-786-3320
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400356602Medicare PIN