Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 0543 | SD |
N | 213ES0000X | Sports Medicine | 0543 | SD |
NPI | 1154935435 |
---|---|
Provider Name | Miss Kelly Nicole Ricke |
First Address | Saint Paul, MN 55107-4403 |
Second Address | Vadnais Heights, MN 55127-7135 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2020 |
Last Update Date | 27/01/2022 |