Healthcare Provider Details

I. General information

NPI: 1881687127
Provider Name (Legal Business Name): JILL E KLOTZBACH N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 W CENTER STREET EXT
MEDINA NY
14103-9557
US

IV. Provider business mailing address

24 RICHMOND AVE
BATAVIA NY
14020-1421
US

V. Phone/Fax

Practice location:
  • Phone: 585-798-1053
  • Fax: 585-798-5639
Mailing address:
  • Phone: 585-798-1053
  • Fax: 585-798-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number276142-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: