Provider Demographics
NPI:1467563023
Name:KOEPKE, CHARLENE VELMA (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:VELMA
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 NE MULBERRY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEE'S SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4533
Mailing Address - Country:US
Mailing Address - Phone:816-389-4137
Mailing Address - Fax:816-389-4140
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:636-386-7810
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO094885367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912719150Medicaid
MO912719150Medicaid