Provider Demographics
NPI:1043945397
Name:VIVATSON, KELSEY (PMHNP-BC, APRN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:VIVATSON
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5459
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5459
Mailing Address - Country:US
Mailing Address - Phone:701-885-4551
Mailing Address - Fax:
Practice Address - Street 1:2534 17TH AVE S STE E
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5215
Practice Address - Country:US
Practice Address - Phone:701-885-4551
Practice Address - Fax:701-757-1351
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR37072363LP0808X
FL11019899363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health