Healthcare Provider Details

I. General information

NPI: 1598078578
Provider Name (Legal Business Name): MICHELLE KOPPEIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 OLD JACKSON RD
FARMINGTON MO
63640-3428
US

IV. Provider business mailing address

1180 OLD JACKSON RD
FARMINGTON MO
63640-3428
US

V. Phone/Fax

Practice location:
  • Phone: 573-760-1700
  • Fax:
Mailing address:
  • Phone: 573-760-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2001019027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: