Provider Demographics
NPI:1962842484
Name:KOOMSON, SALLY (STNA CERTIFIED)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:KOOMSON
Suffix:
Gender:F
Credentials:STNA CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 ARROWBEND CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-9141
Mailing Address - Country:US
Mailing Address - Phone:614-790-0309
Mailing Address - Fax:
Practice Address - Street 1:6254 ARROWBEND CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-9141
Practice Address - Country:US
Practice Address - Phone:614-790-0309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401437590912390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program