Provider Demographics
NPI:1205068962
Name:KLOS, PATRICIA JEAN (ANP-BC)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:KLOS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19680
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9680
Mailing Address - Country:US
Mailing Address - Phone:217-545-5878
Mailing Address - Fax:217-545-8103
Practice Address - Street 1:421 N 9TH ST
Practice Address - Street 2:STE 240
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5317
Practice Address - Country:US
Practice Address - Phone:217-545-5878
Practice Address - Fax:217-545-8103
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007713363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid