1003196114 NPI number — STACY JO KLASS CNP

Table of content: STACY JO KLASS CNP (NPI 1003196114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003196114 NPI number — STACY JO KLASS CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLASS
Provider First Name:
STACY
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003196114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
951 COMMERCE PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45804-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-998-4575
Provider Business Mailing Address Fax Number:
419-998-4586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 BELLEFONTAINE AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LIMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45804-2851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-227-5298
Provider Business Practice Location Address Fax Number:
419-227-5879
Provider Enumeration Date:
08/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  COA12426 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0053941 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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