Basic Information
| Provider Information | |||||||||
| NPI: | 1386373470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENSKE | ||||||||
| FirstName: | MYKAYLA | ||||||||
| MiddleName: | TYLYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FENSKE | ||||||||
| OtherFirstName: | TOBIAS | ||||||||
| OtherMiddleName: | MICHAEL-TYLYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5971 ELLICE TRL W | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551248119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527693708 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 AMERICAN BLVD E STE 8 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527672267 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.