Provider Demographics
NPI:1033555933
Name:KLOTZ, SUSAN M (FNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:KLOTZ
Suffix:
Gender:F
Credentials:FNP-C
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Mailing Address - Street 1:12374 W FARM ROAD 60
Mailing Address - Street 2:
Mailing Address - City:ASH GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65604-8766
Mailing Address - Country:US
Mailing Address - Phone:417-234-3621
Mailing Address - Fax:949-655-7855
Practice Address - Street 1:609 E WELLS ST STE B
Practice Address - Street 2:
Practice Address - City:ASH GROVE
Practice Address - State:MO
Practice Address - Zip Code:65604-9087
Practice Address - Country:US
Practice Address - Phone:417-234-3621
Practice Address - Fax:949-655-7855
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2020-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2013012284363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033555933Medicaid
MO132680609Medicare PIN