1528392024 NPI number — MS. ABIGAIL NICOLE KOETTING MSN, APRN, FNP-BC

Table of content: MS. ABIGAIL NICOLE KOETTING MSN, APRN, FNP-BC (NPI 1528392024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528392024 NPI number — MS. ABIGAIL NICOLE KOETTING MSN, APRN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOETTING
Provider First Name:
ABIGAIL
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, APRN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528392024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 NE TUDOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64086-5696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-256-3814
Provider Business Mailing Address Fax Number:
888-256-9054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 S HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65251-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-592-6550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2009

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: 363LF0000X , with the licence number:  2001015695 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 2001015695 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1528392024 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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