Healthcare Provider Details

I. General information

NPI: 1093285454
Provider Name (Legal Business Name): EMILY BERNARDES KLOCKENGA MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2943 W WHITE OAKS DR STE 1
SPRINGFIELD IL
62704-6596
US

IV. Provider business mailing address

2943 W WHITE OAKS DR STE 1
SPRINGFIELD IL
62704-6596
US

V. Phone/Fax

Practice location:
  • Phone: 217-402-8455
  • Fax:
Mailing address:
  • Phone: 217-402-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: