Healthcare Provider Details

I. General information

NPI: 1619690682
Provider Name (Legal Business Name): MARJORY D KOPPELMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 PINNEY RD
MOVILLE IA
51039-7500
US

IV. Provider business mailing address

69 PINNEY RD
MOVILLE IA
51039-7500
US

V. Phone/Fax

Practice location:
  • Phone: 515-402-6621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA171240
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: