Provider Demographics
NPI:1649979881
Name:KOHTZ, CAROLANN ROBERTA (RN)
Entity type:Individual
Prefix:
First Name:CAROLANN
Middle Name:ROBERTA
Last Name:KOHTZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MISSISSIPPI AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2461
Mailing Address - Country:US
Mailing Address - Phone:309-338-4510
Mailing Address - Fax:
Practice Address - Street 1:1107 MISSISSIPPI AVE APT 305
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2461
Practice Address - Country:US
Practice Address - Phone:309-338-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse