Provider Demographics
NPI:1437929064
Name:KOEBERNIK, NICHOLE MEGAN
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MEGAN
Last Name:KOEBERNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:MEGAN
Other - Last Name:HAGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 E SPEEDWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472-2329
Mailing Address - Country:US
Mailing Address - Phone:501-426-0056
Mailing Address - Fax:
Practice Address - Street 1:205 EAST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:800-467-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide