Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | COA12426 | OH |
NPI | 1003196114 |
---|---|
Provider Name | Stacy Jo Klass |
First Address | Lima, OH 45804-4040 |
Second Address | Lima, OH 45804-2851 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2011 |
Last Update Date | 05/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0053941 | (05) | OH |