Provider Demographics
NPI:1780297218
Name:RUSCH, KELLIE JEAN (APRN, CNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JEAN
Last Name:RUSCH
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 UPTON AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1523
Mailing Address - Country:US
Mailing Address - Phone:612-799-4660
Mailing Address - Fax:
Practice Address - Street 1:671 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1312
Practice Address - Country:US
Practice Address - Phone:651-698-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1747508163W00000X
MN6976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse