Provider Demographics
NPI:1386833770
Name:KLENKE, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:KLENKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MALLETT WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6064
Mailing Address - Country:US
Mailing Address - Phone:843-815-6699
Mailing Address - Fax:843-815-6695
Practice Address - Street 1:7 MALLETT WAY
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6064
Practice Address - Country:US
Practice Address - Phone:843-815-6699
Practice Address - Fax:843-815-6695
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35563207N00000X, 208200000X
OH57013009208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC355635Medicaid
SC355635Medicaid