Provider Demographics
NPI:1245603372
Name:KLEMPKE, VICKIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:KLEMPKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 SOUTHWOOD TER
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5913
Mailing Address - Country:US
Mailing Address - Phone:573-659-0504
Mailing Address - Fax:
Practice Address - Street 1:3218 SOUTHWOOD TER
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5913
Practice Address - Country:US
Practice Address - Phone:573-659-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011001337224Z00000X
MO116728225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant