Individual
KELLY VANVICKLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
49725 COUNTY 83, STAPLES, MN 56479-5280
(218) 894-1515
Mailing address
PO BOX 65, CROSSLAKE, MN 56442-0065
Taxonomy
Speciality
Code
Description
License number
State
363LW0102X
Women's Health Nurse Practitioner
Primary
R147459-6
MN
Other
Enumeration date
02/26/2014
Last updated
09/15/2021
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