Healthcare Provider Details

I. General information

NPI: 1043364714
Provider Name (Legal Business Name): MARY ANN KLEIN RN, FA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4551 KLEIN RD
WATERLOO IL
62298-4343
US

IV. Provider business mailing address

4551 KLEIN RD
WATERLOO IL
62298-4343
US

V. Phone/Fax

Practice location:
  • Phone: 618-978-4614
  • Fax: 315-473-3738
Mailing address:
  • Phone: 618-978-4614
  • Fax: 315-473-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2000152451
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: