Provider Demographics
NPI:1740435551
Name:PENROSE, KELLI JEAN (PA, ATC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JEAN
Last Name:PENROSE
Suffix:
Gender:F
Credentials:PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1901 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2554
Mailing Address - Country:US
Mailing Address - Phone:320-259-4100
Mailing Address - Fax:320-259-8044
Practice Address - Street 1:1901 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-259-4100
Practice Address - Fax:320-259-8044
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer