Provider Demographics
NPI:1154576338
Name:KELLY, ELIZABETH A (LAC)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:900 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1200
Mailing Address - Country:US
Mailing Address - Phone:952-448-9344
Mailing Address - Fax:
Practice Address - Street 1:11000 W 78TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-8010
Practice Address - Country:US
Practice Address - Phone:952-828-9666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1112171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist