Provider Demographics
NPI:1740993369
Name:VANG, KELLY KASHIA (N/A)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KASHIA
Last Name:VANG
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 NOKOMIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3219
Mailing Address - Country:US
Mailing Address - Phone:612-552-8337
Mailing Address - Fax:
Practice Address - Street 1:445 MINNESOTA ST STE 1500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2269
Practice Address - Country:US
Practice Address - Phone:612-594-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst