Provider Demographics
NPI:1508104290
Name:WEDDERBURN, KOEN
Entity Type:Individual
Prefix:
First Name:KOEN
Middle Name:
Last Name:WEDDERBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 BOWMAN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7843
Mailing Address - Country:US
Mailing Address - Phone:740-243-3605
Mailing Address - Fax:
Practice Address - Street 1:4225 BOWMAN MEADOW DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7843
Practice Address - Country:US
Practice Address - Phone:740-243-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN151638164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse