Provider Demographics
NPI:1164409306
Name:KOEPPEL, MARY ANNE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:KOEPPEL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:MARY ANNE
Other - Middle Name:GRIM
Other - Last Name:KOEPPEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:7047 DARDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3511
Mailing Address - Country:US
Mailing Address - Phone:850-893-3772
Mailing Address - Fax:
Practice Address - Street 1:1881 PROFESSIONAL PARK CIR
Practice Address - Street 2:SUITE 80
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4541
Practice Address - Country:US
Practice Address - Phone:850-402-5454
Practice Address - Fax:850-402-5451
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 523132363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics