Provider Demographics
NPI:1578394698
Name:KELLEY, LAURIE L
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:KELLEY
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 1:833 SPRING LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1478
Mailing Address - Country:US
Mailing Address - Phone:218-216-3616
Mailing Address - Fax:
Practice Address - Street 1:833 SPRING LAKE RD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1478
Practice Address - Country:US
Practice Address - Phone:218-216-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA9889131003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant