Healthcare Provider Details

I. General information

NPI: 1316290612
Provider Name (Legal Business Name): JACLYN M VATH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 03/03/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N MAIN ST
CIMARRON KS
67835-8880
US

IV. Provider business mailing address

106 N MAIN ST
CIMARRON KS
67835
US

V. Phone/Fax

Practice location:
  • Phone: 620-855-4456
  • Fax: 620-855-4459
Mailing address:
  • Phone: 620-855-4456
  • Fax: 620-855-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75788
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: