Basic Information
Provider Information | |||||||||
NPI: | 1538441183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLEIN | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIORDANO | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1028 | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475471028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8129965781 | ||||||||
FaxNumber: | 8129960150 | ||||||||
Practice Location | |||||||||
Address1: | 721 W 13TH ST | ||||||||
Address2: | SUITE 325 | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475461855 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8129965781 | ||||||||
FaxNumber: | 8129960150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2011 | ||||||||
LastUpdateDate: | 11/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71003684A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 201035170 | 05 | IN |   | MEDICAID |