Healthcare Provider Details

I. General information

NPI: 1013377720
Provider Name (Legal Business Name): MICHELLE THERESE KOSKI ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E JAMES LEE BLVD
CRESTVIEW FL
32539-2827
US

IV. Provider business mailing address

302 E JAMES LEE BLVD
CRESTVIEW FL
32539-2827
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-1002
  • Fax:
Mailing address:
  • Phone: 850-621-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9293405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: