Provider Demographics
NPI:1437456019
Name:KOOIMAN, MICHELLE MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:KOOIMAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-7003
Mailing Address - Country:US
Mailing Address - Phone:760-252-6304
Mailing Address - Fax:760-252-6337
Practice Address - Street 1:100 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-7003
Practice Address - Country:US
Practice Address - Phone:760-252-6304
Practice Address - Fax:760-252-6337
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily