Healthcare Provider Details

I. General information

NPI: 1164964334
Provider Name (Legal Business Name): CHANDRAWATIE KHEMRAJ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2016
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 BLUEBIRD ST NW
ANDOVER MN
55304-3538
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4688
  • Fax: 763-587-4662
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4884
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: