Healthcare Provider Details

I. General information

NPI: 1508292178
Provider Name (Legal Business Name): REBECCA ANN KOOISTRA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7228 PITTSBORO-MONCURE RD
MONCURE NC
27559
US

IV. Provider business mailing address

301 LLOYD ST
CARRBORO NC
27510-1823
US

V. Phone/Fax

Practice location:
  • Phone: 919-542-4991
  • Fax: 919-542-3726
Mailing address:
  • Phone: 919-942-8741
  • Fax: 919-942-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5006440
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: