Provider Demographics
NPI:1770811895
Name:KOONTZ, THERESA (RN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOONTZ
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 1:2015 SEADRIFT DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1950
Mailing Address - Country:US
Mailing Address - Phone:949-721-1657
Mailing Address - Fax:
Practice Address - Street 1:2646 DUPONT DR STE 250
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-7677
Practice Address - Country:US
Practice Address - Phone:949-261-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247526163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0150193OtherMEDI-CAL