Individual
KIMBERLY RAE KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1702 UNIVERSITY DR S, FARGO, ND 58103-4940
(701) 364-3300
(701) 364-8906
Mailing address
PO BOX 6001, FARGO, ND 58108-6001
(701) 364-3300
(701) 364-8906
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
33100
MN
207N00000X
Dermatology Physician
Primary
5817
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0300403
MEDICA
—
05
—
16323
—
ND
01
—
25535
BLUE SHIELD
ND
01
—
511R8KE
BLUE SHIELD
MN
01
—
772090400
MEDICAL ASSISTANCE
MN
01
—
HP17495
HEALTHPARTNERS
—
Enumeration date
08/26/2005
Last updated
08/25/2011
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