Provider Demographics
NPI:1285722926
Name:FISHER, KELLY R (LRD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:FISHER
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:NAGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:209 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4441
Practice Address - Country:US
Practice Address - Phone:701-323-5590
Practice Address - Fax:701-323-8109
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND440133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59579Medicaid
ND59579Medicaid