Healthcare Provider Details

I. General information

NPI: 1619659471
Provider Name (Legal Business Name): KAITLYN JUDITH PROCHNOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 MAIN ST N STE 300
STILLWATER MN
55082-6788
US

IV. Provider business mailing address

270 MAIN ST N STE 300
STILLWATER MN
55082-6788
US

V. Phone/Fax

Practice location:
  • Phone: 651-342-1039
  • Fax: 651-342-1428
Mailing address:
  • Phone: 651-342-1039
  • Fax: 651-342-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14575
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: