Provider Demographics
NPI:1427626415
Name:MAGRUM, KELLY (CNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAGRUM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MAGRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:KELLY HAGA
Mailing Address - Street 1:4909 SHELBURNE ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5605
Mailing Address - Country:US
Mailing Address - Phone:701-570-0482
Mailing Address - Fax:
Practice Address - Street 1:309 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5258
Practice Address - Country:US
Practice Address - Phone:701-580-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X
172A00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1482572Medicaid