Provider Demographics
NPI:1811300742
Name:KELLY, SUZANNE (CNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
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 1:218 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-2533
Mailing Address - Country:US
Mailing Address - Phone:320-685-3020
Mailing Address - Fax:
Practice Address - Street 1:218 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-2533
Practice Address - Country:US
Practice Address - Phone:320-685-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 147009-5363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR 147009-5OtherNURSING LICENSE