Provider Demographics
NPI:1780939314
Name:KELLY, CAROL LYNNE (CNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CNP
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 346
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-0346
Mailing Address - Country:US
Mailing Address - Phone:218-368-7795
Mailing Address - Fax:218-444-9252
Practice Address - Street 1:1405 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5113
Practice Address - Country:US
Practice Address - Phone:218-368-7795
Practice Address - Fax:218-444-9252
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 89344-0363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily