Provider Demographics
NPI:1003840174
Name:KLOCKMANN, MARY KAY (NP)
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:KLOCKMANN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W ATEN RD
Mailing Address - Street 2:IMPERIAL
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:608 G STREET
Practice Address - Street 2:BRAWLEY
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2567
Practice Address - Country:US
Practice Address - Phone:760-351-1011
Practice Address - Fax:760-545-0247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9766NP364SF0001X
CA402384RN364SF0001X
CARN402384363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP21747Medicare UPIN