Provider Demographics
NPI:1336217900
Name:PRUETT, KELLY D (APN)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:D
Last Name:PRUETT
Suffix:
Gender:M
Credentials:APN
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-751-9746
Practice Address - Fax:605-328-6512
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN7888363L00000X
ARA003595363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3C812Medicare PIN