Provider Demographics
NPI:1508865049
Name:KLINEFELTER, GERRY A (RN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:GERRY
Middle Name:A
Last Name:KLINEFELTER
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 N CHENEY ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2741
Mailing Address - Country:US
Mailing Address - Phone:217-824-2524
Mailing Address - Fax:217-824-2588
Practice Address - Street 1:1141 N CHENEY ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2741
Practice Address - Country:US
Practice Address - Phone:217-824-2524
Practice Address - Fax:217-824-2588
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL952810Medicare ID - Type Unspecified
ILR17460Medicare UPIN