Provider Demographics
NPI:1801266291
Name:GARDUNO-KLYNSTRA, KATHERINE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:GARDUNO-KLYNSTRA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N ELM AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8887
Mailing Address - Country:US
Mailing Address - Phone:517-780-5006
Mailing Address - Fax:
Practice Address - Street 1:3500 N ELM AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8887
Practice Address - Country:US
Practice Address - Phone:517-780-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2016-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704268823363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health