Provider Demographics
NPI:1881687127
Name:KLOTZBACH, JILL E (NP)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:E
Last Name:KLOTZBACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1421
Mailing Address - Country:US
Mailing Address - Phone:585-798-1053
Mailing Address - Fax:585-798-5639
Practice Address - Street 1:11075 W CENTER STREET EXT
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-9557
Practice Address - Country:US
Practice Address - Phone:585-798-1053
Practice Address - Fax:585-798-5639
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276142-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02081836Medicaid
NY02081836Medicaid
NYCC4007Medicare ID - Type UnspecifiedMEDICARE NUMBER