Provider Demographics
NPI:1679250385
Name:DOCKENDORF, KELSEY MAE (CNP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MAE
Last Name:DOCKENDORF
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 WILDERNESS DR
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-3127
Mailing Address - Country:US
Mailing Address - Phone:320-248-5083
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:320-248-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-04
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily