Provider Demographics
NPI:1497882179
Name:CLUTE, KAYLEEN WEINMAN (CRNP-PEDS)
Entity Type:Individual
Prefix:MRS
First Name:KAYLEEN
Middle Name:WEINMAN
Last Name:CLUTE
Suffix:
Gender:F
Credentials:CRNP-PEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3715
Mailing Address - Country:US
Mailing Address - Phone:410-315-8380
Mailing Address - Fax:
Practice Address - Street 1:1406 SOUTH CRAIN HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4086
Practice Address - Country:US
Practice Address - Phone:410-768-2231
Practice Address - Fax:410-760-4522
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134010363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH703655WMedicare ID - Type UnspecifiedPROV # KAYLEEN W CLUTE