Basic Information
| Provider Information | |||||||||
| NPI: | 1255304762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KYLE | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 1ST DRIVE NW | ||||||||
| Address2: | MAYO CLINIC HEALTH SYSTEM | ||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 96001726 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 1612 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 11841 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 11841 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.