Healthcare Provider Details

I. General information

NPI: 1043262876
Provider Name (Legal Business Name): STEPHANIE GILLETTE MCKEEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE GILLETTE MD

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36105 LEHINGER RD
BIGFORK MN
56628-4413
US

IV. Provider business mailing address

36105 LEHINGER RD
BIGFORK MN
56628-4413
US

V. Phone/Fax

Practice location:
  • Phone: 218-743-3369
  • Fax:
Mailing address:
  • Phone: 218-743-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35208
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: