Healthcare Provider Details

I. General information

NPI: 1942476734
Provider Name (Legal Business Name): PAMELA LYNN KLINKNER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NE SUITE 2
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

2680 LEONARD ST NE SUITE 2
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-1515
  • Fax: 616-224-2070
Mailing address:
  • Phone: 616-949-9944
  • Fax: 616-949-4978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: