Healthcare Provider Details

I. General information

NPI: 1457278657
Provider Name (Legal Business Name): ALEXANDRA MARIE KLOFSTAD LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 5TH AVE W
GRAND MARAIS MN
55604-3017
US

IV. Provider business mailing address

58 HAYS CIR
SILVER BAY MN
55614-1242
US

V. Phone/Fax

Practice location:
  • Phone: 218-387-3040
  • Fax:
Mailing address:
  • Phone: 763-614-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3503
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: