1578512000 NPI number — MS. KELSY LENORE KUEHN PAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578512000 NPI number — MS. KELSY LENORE KUEHN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUEHN
Provider First Name:
KELSY
Provider Middle Name:
LENORE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578512000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 COMMERCE DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-4925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-968-5042
Provider Business Mailing Address Fax Number:
651-968-5904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1661 SAINT ANTHONY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-968-5300
Provider Business Practice Location Address Fax Number:
651-646-0205
Provider Enumeration Date:
05/10/2006

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: 363A00000X , with the licence number:  9571 , 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)

  • Identifier: 388037100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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