Healthcare Provider Details

I. General information

NPI: 1205498078
Provider Name (Legal Business Name): ALEXANDRA DOMINIQUE KOELTZOW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W GORE ST
ORLANDO FL
32806-1134
US

IV. Provider business mailing address

32 W GORE ST
ORLANDO FL
32806-1134
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-3581
  • Fax: 321-843-5177
Mailing address:
  • Phone: 321-841-3581
  • Fax: 321-843-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11003194
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN9390112
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11003194
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: