| Doctor Name: | KELLY VANVICKLE |
| NPI Number: | 1013332105 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | R147459-6 |
| Business Practice Address: | 49725 County 83 Staples, MN - 564795280 |
| Business Phone Number: | 2188941515 |
| Business Fax Number: | |
| Mailing Address: | 49725 County 83, STAPLES |
| State: | MN |
| Postal Code: | 564795280 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 02/26/2014 |
| NPI Last Update Date: | 02/26/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LW0102X |
| License Number: | R147459-6 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Women's Health |
| Taxonomy Definition: | |