Provider Demographics
NPI:1093529919
Name:KELLY, ERIN MICHELLE (MAOM)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MICHELLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 GREENHAVEN BAY
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-9237
Mailing Address - Country:US
Mailing Address - Phone:507-400-5680
Mailing Address - Fax:
Practice Address - Street 1:22 GREENHAVEN BAY
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-9237
Practice Address - Country:US
Practice Address - Phone:507-400-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1842171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist