Provider Demographics
NPI:1164005690
Name:KOETZLE, PAULINE LUCILA
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:LUCILA
Last Name:KOETZLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2701
Practice Address - Country:US
Practice Address - Phone:954-895-3679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program