Provider Demographics
NPI:1629023940
Name:KOPPENAAL, GERALDINE S (RNCS)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:S
Last Name:KOPPENAAL
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3813
Mailing Address - Country:US
Mailing Address - Phone:781-665-4295
Mailing Address - Fax:
Practice Address - Street 1:106 WEST FOSTER STREET
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-665-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116810163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0036916OtherNEIGHBORHOOD HEALTH PLAN
MAPN0658OtherBLUE CROSS
MANS0302Medicare ID - Type Unspecified
MA0036916OtherNEIGHBORHOOD HEALTH PLAN