Provider Demographics
NPI:1700481348
Name:KLOSE, STEPHANIE DIANNE (CHPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:KLOSE
Suffix:
Gender:F
Credentials:CHPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 CRANBERRY CT
Mailing Address - Street 2:
Mailing Address - City:MONETA
Mailing Address - State:VA
Mailing Address - Zip Code:24121-6359
Mailing Address - Country:US
Mailing Address - Phone:540-238-8061
Mailing Address - Fax:
Practice Address - Street 1:1125 CRANBERRY CT
Practice Address - Street 2:
Practice Address - City:MONETA
Practice Address - State:VA
Practice Address - Zip Code:24121-6359
Practice Address - Country:US
Practice Address - Phone:540-238-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
270101031155516183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician