Provider Demographics
NPI:1184259038
Name:KLINEFELTER, AIMEE FONDELL (PA-C)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:FONDELL
Last Name:KLINEFELTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 N LAWNDALE AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5996
Mailing Address - Country:US
Mailing Address - Phone:631-903-5131
Mailing Address - Fax:
Practice Address - Street 1:7047 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1015
Practice Address - Country:US
Practice Address - Phone:773-303-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant