Provider Demographics
NPI:1700831542
Name:KOEHLER, ELLEN L (CRNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:L
Other - Last Name:SEEBERGER
Other - Suffix:V
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-6598
Mailing Address - Fax:410-328-3577
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6598
Practice Address - Fax:410-328-3577
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR145838363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD640729-01OtherBC/BS
MD404708700Medicaid
MD404708700Medicaid
MDN192Medicare PIN
MD640729-01OtherBC/BS