Provider Demographics
NPI:1558510693
Name:FELLOWS, KIM LACEY (NP-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:LACEY
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:LACEY
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-373-2384
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-369-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-13
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA124361363LF0000X
WI12287-33363LF0000X
MNR 189805-9363LF0000X
MN456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily