Provider Demographics
NPI:1184618688
Name:KOEP DICKEY, SHARON MARIE (MSN)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:MARIE
Last Name:KOEP DICKEY
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:MARIE
Other - Last Name:KOEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:19425 EVANS ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19425 EVANS ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1074
Practice Address - Country:US
Practice Address - Phone:763-389-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0962504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN326462300Medicaid
Q43155Medicare UPIN
MN326462300Medicaid