Healthcare Provider Details

I. General information

NPI: 1477468601
Provider Name (Legal Business Name): ANGIE MARIE KOELLE BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E MOUNTAIN VIEW ST
BARSTOW CA
92311-3004
US

IV. Provider business mailing address

14180 CREE RD
APPLE VALLEY CA
92307-5765
US

V. Phone/Fax

Practice location:
  • Phone: 760-957-3323
  • Fax:
Mailing address:
  • Phone: 760-220-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number95165658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: