Provider Demographics
NPI:1346607587
Name:NEELY, KIMBERLY R (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:NEELY
Suffix:
Gender:F
Credentials:AGACNP-BC
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 13780
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:ALTRU CANCER CENTER
Practice Address - Street 2:960 S. COLUMBIA ROAD
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:304-781-5139
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND201611363LA2100X, 363LA2200X, 363LG0600X
WV83344163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health