Provider Demographics
NPI:1669869582
Name:KODOE, KOFFI (NURSE)
Entity type:Individual
Prefix:
First Name:KOFFI
Middle Name:
Last Name:KODOE
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21223 HOLLIS AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429
Mailing Address - Country:US
Mailing Address - Phone:202-294-7955
Mailing Address - Fax:
Practice Address - Street 1:21223 HOLLIS AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429
Practice Address - Country:US
Practice Address - Phone:202-294-7955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3216753140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric