Provider Demographics
NPI:1952647760
Name:TINDALL, KLANCY
Entity Type:Individual
Prefix:
First Name:KLANCY
Middle Name:
Last Name:TINDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KLANCY
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:142 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GWINNER
Mailing Address - State:ND
Mailing Address - Zip Code:58040-4200
Mailing Address - Country:US
Mailing Address - Phone:701-680-9572
Mailing Address - Fax:
Practice Address - Street 1:1311 VANDER HORCK AVENUE
Practice Address - Street 2:
Practice Address - City:BRITTON
Practice Address - State:SD
Practice Address - Zip Code:57430-0939
Practice Address - Country:US
Practice Address - Phone:605-448-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD29OA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist