Basic Information
Provider Information
NPI: 1033557285
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GILLES
FirstName: KELSEY
MiddleName: LEIGH
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6363 FRANCE AVE S
Address2:  
City: EDINA
State: MN
PostalCode: 554352129
CountryCode: US
TelephoneNumber: 9522309100
FaxNumber:  
Practice Location
Address1: 6363 FRANCE AVE S
Address2:  
City: EDINA
State: MN
PostalCode: 554352129
CountryCode: US
TelephoneNumber: 9522309100
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/10/2013
LastUpdateDate: 10/02/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084P0800X59526MNY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry

No ID Information.


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