Provider Demographics
NPI:1730100686
Name:KOEHN, KIMBERLY KAYE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAYE
Last Name:KOEHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-337-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX540281363L00000X
TXAP107355363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209310601Medicaid
TX453828Medicare PIN
TX673862Medicare PIN
TX209310601Medicaid