1407060825 NPI number — MRS. SANDRA CAROL KLATKE LPN

Table of content: MRS. SANDRA CAROL KLATKE LPN (NPI 1407060825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407060825 NPI number — MRS. SANDRA CAROL KLATKE LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLATKE
Provider First Name:
SANDRA
Provider Middle Name:
CAROL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOTTAVI
Provider Other First Name:
SANDRA
Provider Other Middle Name:
CAROL
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1407060825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15685 480TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMARACK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55787-4424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-426-3605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 NORTH 4TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-1034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-998-3778
Provider Business Practice Location Address Fax Number:
218-998-3187
Provider Enumeration Date:
05/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  L0526034 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)