Provider Demographics
NPI:1043364714
Name:KLEIN, MARY ANN (RN, FA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:KLEIN
Suffix:
Gender:F
Credentials:RN, FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 KLEIN RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-4343
Mailing Address - Country:US
Mailing Address - Phone:618-978-4614
Mailing Address - Fax:315-473-3738
Practice Address - Street 1:4551 KLEIN RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-4343
Practice Address - Country:US
Practice Address - Phone:618-978-4614
Practice Address - Fax:315-473-3738
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000152451163W00000X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist