Healthcare Provider Details

I. General information

NPI: 1124055686
Provider Name (Legal Business Name): MARY JO KOLLER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 REDMOND RD NW
ROME GA
30165-1416
US

IV. Provider business mailing address

221 TECHNOLOGY PKWY NW
ROME GA
30165-1369
US

V. Phone/Fax

Practice location:
  • Phone: 706-235-3855
  • Fax: 706-290-2721
Mailing address:
  • Phone: 706-295-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN218765
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: