Provider Demographics
NPI:1528392024
Name:KOETTING, ABIGAIL NICOLE (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:ABIGAIL
Middle Name:NICOLE
Last Name:KOETTING
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 NE TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5696
Mailing Address - Country:US
Mailing Address - Phone:888-256-3814
Mailing Address - Fax:888-256-9054
Practice Address - Street 1:10 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-2510
Practice Address - Country:US
Practice Address - Phone:573-592-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001015695363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1528392024Medicaid
MOP00910474Medicare PIN
MO1528392024Medicaid