Provider Demographics
NPI:1447579743
Name:KUFFENKAM, KERRY LYNN (MD)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:LYNN
Last Name:KUFFENKAM
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 1:100 LAKE TRAVERSE DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7046
Mailing Address - Country:US
Mailing Address - Phone:605-698-7606
Mailing Address - Fax:605-742-0183
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:605-742-0183
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59733208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice