Healthcare Provider Details

I. General information

NPI: 1003840174
Provider Name (Legal Business Name): MARY KAY KLOCKMANN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 G STREET BRAWLEY
BRAWLEY CA
92227-2567
US

IV. Provider business mailing address

516 W ATEN RD IMPERIAL
IMPERIAL CA
92251-9805
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-1011
  • Fax: 760-545-0247
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number9766NP
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number402384RN
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN402384
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: