Provider Demographics
NPI:1013332105
Name:VANVICKLE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VANVICKLE
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:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-0065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR147459-6363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health