Basic Information
| Provider Information | |||||||||
| NPI: | 1992216618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEARSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 DALY ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551023211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513434891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2945 HAZELWOOD ST | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
| FaxNumber: | 6512327940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2017 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1618718 | MN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 5448 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.