1619272572 NPI number — JENELLE PHILIPCZYK KELLEY PA-C

Table of content: JENELLE PHILIPCZYK KELLEY PA-C (NPI 1619272572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619272572 NPI number — JENELLE PHILIPCZYK KELLEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
JENELLE
Provider Middle Name:
PHILIPCZYK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILIPCZYK
Provider Other First Name:
JENELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619272572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 WESTGATE DR
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-312-1505
Provider Business Mailing Address Fax Number:
651-641-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6363 FRANCE AVE S
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-312-1700
Provider Business Practice Location Address Fax Number:
952-920-4148
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1525 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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