Provider Demographics
NPI:1164498804
Name:KELLS, MARCIA S (RN CNP)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:S
Last Name:KELLS
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-1166
Mailing Address - Country:US
Mailing Address - Phone:507-247-5921
Mailing Address - Fax:507-247-5184
Practice Address - Street 1:240 WILLOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-1166
Practice Address - Country:US
Practice Address - Phone:507-247-5921
Practice Address - Fax:507-247-5184
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0790585207Q00000X
MN0790585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN863387800Medicaid
MN863387800Medicaid
S43418Medicare UPIN