Basic Information
| Provider Information | |||||||||
| NPI: | 1003840174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOCKMANN | ||||||||
| FirstName: | MARY KAY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 W ATEN RD | ||||||||
| Address2: | IMPERIAL | ||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922519805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 G STREET | ||||||||
| Address2: | BRAWLEY | ||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922272567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603511011 | ||||||||
| FaxNumber: | 7605450247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 9766NP | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 364SF0001X | 402384RN | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363L00000X | RN402384 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.