Healthcare Provider Details

I. General information

NPI: 1356972236
Provider Name (Legal Business Name): JENNA M KRAUTKREMER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 3RD ST
GAYLORD MN
55334-2297
US

IV. Provider business mailing address

PO BOX 903
GAYLORD MN
55334-0903
US

V. Phone/Fax

Practice location:
  • Phone: 507-237-2911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2508
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: