Provider Demographics
NPI:1033734272
Name:KLAVERKAMP, KRISTINA (MSPA)
Entity Type:Individual
Prefix:MISS
First Name:KRISTINA
Middle Name:
Last Name:KLAVERKAMP
Suffix:
Gender:F
Credentials:MSPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FRANK SCOTT PKWY W STE 716
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5007
Mailing Address - Country:US
Mailing Address - Phone:618-355-0880
Mailing Address - Fax:
Practice Address - Street 1:2810 FRANK SCOTT PKWY W STE 716
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5007
Practice Address - Country:US
Practice Address - Phone:618-355-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO1176339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant