Provider Demographics
NPI:1407949415
Name:KOENEN, LINDA (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:KOENEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 W ANTELOPE DR
Mailing Address - Street 2:#290
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-776-0880
Mailing Address - Fax:801-773-7399
Practice Address - Street 1:1580 W ANTELOPE DR
Practice Address - Street 2:#290
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-776-0880
Practice Address - Fax:801-773-7399
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT219731-4405207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005513610Medicare ID - Type Unspecified
Q51989Medicare UPIN