Healthcare Provider Details

I. General information

NPI: 1184618688
Provider Name (Legal Business Name): SHARON MARIE KOEP DICKEY MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHARON MARIE KOEP FNP

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19425 EVANS ST NW
ELK RIVER MN
55330-1074
US

IV. Provider business mailing address

19425 EVANS ST NW
ELK RIVER MN
55330-1074
US

V. Phone/Fax

Practice location:
  • Phone: 763-389-7686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0962504
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: