Provider Demographics
NPI:1518085109
Name:KOELLNER, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:KOELLNER
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 1:6760 LITTLE CABIN RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-8517
Mailing Address - Country:US
Mailing Address - Phone:563-332-8609
Mailing Address - Fax:
Practice Address - Street 1:2200 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5300
Practice Address - Country:US
Practice Address - Phone:563-391-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist