Provider Demographics
NPI:1093285454
Name:KLOCKENGA, EMILY BERNARDES (MED)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:BERNARDES
Last Name:KLOCKENGA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2943 W WHITE OAKS DR STE 1
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6596
Mailing Address - Country:US
Mailing Address - Phone:217-402-8455
Mailing Address - Fax:
Practice Address - Street 1:2943 W WHITE OAKS DR STE 1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6596
Practice Address - Country:US
Practice Address - Phone:217-402-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator