Provider Demographics
NPI:1326489568
Name:KOOISTRA, LINDA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:MARIE
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10975 ROCKY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-0614
Mailing Address - Country:US
Mailing Address - Phone:479-841-2645
Mailing Address - Fax:
Practice Address - Street 1:10971 ROCKY CREEK RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-0614
Practice Address - Country:US
Practice Address - Phone:479-841-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1557111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor