Provider Demographics
NPI:1215939053
Name:KLOS, LYNETTE CORRINE (CRNA)
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:CORRINE
Last Name:KLOS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7595 TIMBERLORE TRL
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-8728
Mailing Address - Country:US
Mailing Address - Phone:218-741-3340
Mailing Address - Fax:
Practice Address - Street 1:901 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2348
Practice Address - Country:US
Practice Address - Phone:218-741-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR070892-0367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered