1821182296 NPI number — MARY B KOOLMO APRN, CNP

Table of content: MARY B KOOLMO APRN, CNP (NPI 1821182296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821182296 NPI number — MARY B KOOLMO APRN, CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOOLMO
Provider First Name:
MARY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DENTZ
Provider Other First Name:
MARY
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821182296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
347 N. SMITH AVE.
Provider Second Line Business Mailing Address:
MS 70-302
Provider Business Mailing Address City Name:
ST. PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-220-6728
Provider Business Mailing Address Fax Number:
651-220-5231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
347 SMITH AVE N
Provider Second Line Business Practice Location Address:
MS 70-302
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-220-6728
Provider Business Practice Location Address Fax Number:
651-220-5231
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  R44402 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: R119628-5 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000Z8736 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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