Provider Demographics
NPI:1982433504
Name:FARGO, KELSEE
Entity type:Individual
Prefix:
First Name:KELSEE
Middle Name:
Last Name:FARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1766 COUNTY ROAD 33
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-8004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1766 COUNTY ROAD 33
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:NE
Practice Address - Zip Code:68007-8004
Practice Address - Country:US
Practice Address - Phone:608-341-0729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI254820163W00000X
NE155699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse