Provider Demographics
NPI:1942525928
Name:KELLY, TIMOTHY ANTON
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ANTON
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7954 BROOKLYN BOULAVARD
Mailing Address - Street 2:7954
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445
Mailing Address - Country:US
Mailing Address - Phone:952-210-2131
Mailing Address - Fax:
Practice Address - Street 1:7954 BROOKLYN BOULAVARD
Practice Address - Street 2:7954
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445
Practice Address - Country:US
Practice Address - Phone:952-210-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
MN1536744251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN27-2211896OtherHOMECARE
MN621610OtherHOMECARE