Provider Demographics
NPI:1447628912
Name:SHEA, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20743 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-7415
Mailing Address - Country:US
Mailing Address - Phone:218-770-2210
Mailing Address - Fax:
Practice Address - Street 1:20743 RED OAK DR.
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-770-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN83156390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program