Provider Demographics
NPI:1669892964
Name:HENKELMAN, KAITLYN (DO)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:HENKELMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:KOWAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8455 FLYING CLOUD DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3974
Practice Address - Country:US
Practice Address - Phone:952-993-7400
Practice Address - Fax:952-993-7431
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine