Provider Demographics
NPI:1992256382
Name:HEDBLAD, KELLY JEAN (ACNPC-AG)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:HEDBLAD
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 IDAHO AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3350
Mailing Address - Country:US
Mailing Address - Phone:651-487-5721
Mailing Address - Fax:
Practice Address - Street 1:2945 HAZELWOOD ST STE 100
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1241
Practice Address - Country:US
Practice Address - Phone:651-232-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4856363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner