Healthcare Provider Details

I. General information

NPI: 1487623435
Provider Name (Legal Business Name): CHERYL MARIE KLENOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 WEST COUNTY ROAD C
ROSEVILLE MN
55113-1304
US

IV. Provider business mailing address

1835 WEST COUNTY ROAD C
ROSEVILLE MN
55113-1304
US

V. Phone/Fax

Practice location:
  • Phone: 763-785-4500
  • Fax: 763-785-7779
Mailing address:
  • Phone: 763-785-4500
  • Fax: 763-785-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number36591
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: