Provider Demographics
NPI:1972122331
Name:MINOR, KELLY (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MINOR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5429 ENCELIA DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-1335
Mailing Address - Country:US
Mailing Address - Phone:239-207-5220
Mailing Address - Fax:
Practice Address - Street 1:5429 ENCELIA DR
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-1335
Practice Address - Country:US
Practice Address - Phone:760-830-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184255367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife