Provider Demographics
NPI:1255765095
Name:KOEHLER, MARY BETH (PNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DOCTORS CIR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4097
Mailing Address - Country:US
Mailing Address - Phone:910-754-7075
Mailing Address - Fax:910-754-2158
Practice Address - Street 1:14 DOCTORS CIR
Practice Address - Street 2:SUITE 3
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4097
Practice Address - Country:US
Practice Address - Phone:910-754-7075
Practice Address - Fax:910-754-2158
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC162702363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics