Provider Demographics
NPI:1619492154
Name:KOOISTRA, KATHRYN LORRAINE (CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LORRAINE
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 JASMINE CT
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-4119
Mailing Address - Country:US
Mailing Address - Phone:404-909-1228
Mailing Address - Fax:
Practice Address - Street 1:930 3RD ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6967
Practice Address - Country:US
Practice Address - Phone:336-890-3200
Practice Address - Fax:336-890-3290
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCNM653367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife