Healthcare Provider Details

I. General information

NPI: 1457971665
Provider Name (Legal Business Name): BROOKE ASHLEY KOOPMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

2493 SEVEN OAKS DR
SAINT CLOUD FL
34772-7822
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5600
  • Fax:
Mailing address:
  • Phone: 216-952-9867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.353718
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9526861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: