Provider Demographics
NPI:1821182296
Name:KOOLMO, MARY B (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:KOOLMO
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:DENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:347 N. SMITH AVE.
Mailing Address - Street 2:MS 70-302
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-220-6728
Mailing Address - Fax:651-220-5231
Practice Address - Street 1:347 SMITH AVE N
Practice Address - Street 2:MS 70-302
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2387
Practice Address - Country:US
Practice Address - Phone:651-220-6728
Practice Address - Fax:651-220-5231
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR44402208000000X
MNR119628-5363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z8736Medicaid
348404501Medicare PIN
NM000Z8736Medicaid