Provider Demographics
NPI:1679565774
Name:KYLLO, JENNIFER H (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:KYLLO
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:CHILDREN'S HEALTH CARE
Mailing Address - Street 2:2910 CENTRE POINTE DRIVE, 35-121A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:CHILDREN'S SPECIALTY CLINIC-DIABETES/ENDOCRINOLOGY-STPL
Practice Address - Street 2:347 NORTH SMITH AVENUE
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6818
Practice Address - Fax:651-220-6064
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN391142080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328214700Medicaid
MN328214700Medicaid