Provider Demographics
NPI:1295279958
Name:KOOISTRA, MILLIE
Entity type:Individual
Prefix:
First Name:MILLIE
Middle Name:
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4614
Mailing Address - Country:US
Mailing Address - Phone:812-231-5678
Mailing Address - Fax:812-231-4475
Practice Address - Street 1:110 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4614
Practice Address - Country:US
Practice Address - Phone:812-231-5678
Practice Address - Fax:812-231-4475
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28174208A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily