Healthcare Provider Details

I. General information

NPI: 1033555933
Provider Name (Legal Business Name): SUSAN M KLOTZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E WELLS ST STE B
ASH GROVE MO
65604-9087
US

IV. Provider business mailing address

12374 W FARM ROAD 60
ASH GROVE MO
65604-8766
US

V. Phone/Fax

Practice location:
  • Phone: 417-234-3621
  • Fax: 949-655-7855
Mailing address:
  • Phone: 417-234-3621
  • Fax: 949-655-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013012284
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: