Basic Information
| Provider Information | |||||||||
| NPI: | 1912358219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNATA | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENE | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8290 UNIVERSITY AVE NE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554321847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637869543 | ||||||||
| FaxNumber: | 7637863320 | ||||||||
| Practice Location | |||||||||
| Address1: | 8290 UNIVERSITY AVE NE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554321847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637869543 | ||||||||
| FaxNumber: | 7637863320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2016 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 12312 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.