Healthcare Provider Details

I. General information

NPI: 1215328521
Provider Name (Legal Business Name): THEA KOLTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THEA EPPLE

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 MERIDIAN LN
TOWSON MD
21286-5205
US

IV. Provider business mailing address

202 MERIDIAN LN
TOWSON MD
21286-5205
US

V. Phone/Fax

Practice location:
  • Phone: 443-413-1904
  • Fax:
Mailing address:
  • Phone: 443-413-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR184684
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: