Provider Demographics
NPI:1154319705
Name:KNUDTEN, KRISTINE LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LEONARD
Last Name:KNUDTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HENNEPIN AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336
Mailing Address - Country:US
Mailing Address - Phone:320-864-3121
Mailing Address - Fax:320-864-7887
Practice Address - Street 1:1805 HENNEPIN AVE NORTH
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:320-864-7887
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G41377Medicare UPIN