Provider Demographics
NPI:1205498078
Name:KOELTZOW, ALEXANDRA DOMINIQUE (APRN)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DOMINIQUE
Last Name:KOELTZOW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8850 ABBOTSBURY DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6708
Mailing Address - Country:US
Mailing Address - Phone:407-201-9163
Mailing Address - Fax:
Practice Address - Street 1:9400 TURKEY LAKE RD # MP453
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:321-842-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9390112163WM0705X
FL11003194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical