Provider Demographics
NPI:1134551641
Name:MASON, KELSEY J (FNP-BC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:J
Last Name:MASON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:J
Other - Last Name:HOYT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:2 CARLSON PKWY N STE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:763-367-7110
Mailing Address - Fax:763-317-1566
Practice Address - Street 1:2 CARLSON PKWY N STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4485
Practice Address - Country:US
Practice Address - Phone:618-961-1950
Practice Address - Fax:618-961-1968
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041409099163W00000X
IL209010593207N00000X, 363L00000X
MO2020026942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid