Basic Information
| Provider Information | |||||||||
| NPI: | 1164498804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLS | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | RN CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561781166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475921 | ||||||||
| FaxNumber: | 5072475184 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561781166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475921 | ||||||||
| FaxNumber: | 5072475184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R0790585 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 0790585 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 863387800 | 05 | MN | MEDICAID |