Healthcare Provider Details

I. General information

NPI: 1710152020
Provider Name (Legal Business Name): HEATHER LYNN KLUCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 OGDEN AVE CLINTON CLINIC
CLINTON WI
53525-9007
US

IV. Provider business mailing address

1115 EAGLE CT
EDGERTON WI
53534-8548
US

V. Phone/Fax

Practice location:
  • Phone: 608-676-2206
  • Fax: 608-676-4029
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3201
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3201-23
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: