Healthcare Provider Details

I. General information

NPI: 1508543919
Provider Name (Legal Business Name): KOA HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 142ND AVE NE
HAM LAKE MN
55304-6842
US

IV. Provider business mailing address

11468 MARKETPLACE DR N STE 600-1248
CHAMPLIN MN
55316-3872
US

V. Phone/Fax

Practice location:
  • Phone: 701-330-5573
  • Fax:
Mailing address:
  • Phone: 701-330-5573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA BRITTAIN
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 701-330-5573