Provider Demographics
NPI:1063883338
Name:NGUYEN, KELLY L (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13819 HANSON BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-7608
Mailing Address - Country:US
Mailing Address - Phone:763-392-4001
Mailing Address - Fax:763-862-2091
Practice Address - Street 1:13819 HANSON BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-7608
Practice Address - Country:US
Practice Address - Phone:763-392-4001
Practice Address - Fax:763-862-2091
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3009765363LF0000X
MN6445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201332080Medicaid
KY7100366930Medicaid
KY7100366930Medicaid