Healthcare Provider Details

I. General information

NPI: 1821182296
Provider Name (Legal Business Name): MARY B KOOLMO APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY B DENTZ CPNP

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 SMITH AVE N MS 70-302
SAINT PAUL MN
55102-2387
US

IV. Provider business mailing address

347 N. SMITH AVE. MS 70-302
ST. PAUL MN
55102
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6728
  • Fax: 651-220-5231
Mailing address:
  • Phone: 651-220-6728
  • Fax: 651-220-5231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR44402
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR119628-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: