Provider Demographics
NPI:1336991538
Name:KOIVISTO, MIKAELA ROSE
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:ROSE
Last Name:KOIVISTO
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 1:9849 WILLOW WIND DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6508
Mailing Address - Country:US
Mailing Address - Phone:814-505-3434
Mailing Address - Fax:
Practice Address - Street 1:4401 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3413
Practice Address - Country:US
Practice Address - Phone:405-834-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program