Provider Demographics
NPI:1922743103
Name:CHEVALIER, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CHEVALIER
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 1:1463 I94 BUSINESS LOOP E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-6434
Mailing Address - Country:US
Mailing Address - Phone:701-227-7506
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:1463 I94 BUSINESS LOOP E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-6434
Practice Address - Country:US
Practice Address - Phone:701-227-7506
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR447687163W00000X
NDR47687363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse