Basic Information
| Provider Information | |||||||||
| NPI: | 1215939053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLOS | ||||||||
| FirstName: | LYNETTE | ||||||||
| MiddleName: | CORRINE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 TIMBERLORE TRL | ||||||||
| Address2: | |||||||||
| City: | COOK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557238728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 9TH ST N | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R070892-0 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.