Provider Demographics
NPI:1164086559
Name:KOEKEMOER, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:KOEKEMOER
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 1:4713 WINGED FOOT LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-8050
Mailing Address - Country:US
Mailing Address - Phone:870-243-0418
Mailing Address - Fax:
Practice Address - Street 1:4713 WINGED FOOT LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8050
Practice Address - Country:US
Practice Address - Phone:870-243-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR69806163W00000X
AR222001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse