Healthcare Provider Details

I. General information

NPI: 1174567556
Provider Name (Legal Business Name): SUSAN DIANE KOEPP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BROAD STREET EXT
ORIENTAL NC
28571-9790
US

IV. Provider business mailing address

PO BOX 383 1101 BROAD ST EXT
ORIENTAL NC
28571-9790
US

V. Phone/Fax

Practice location:
  • Phone: 252-249-2220
  • Fax: 252-249-2275
Mailing address:
  • Phone: 252-249-2220
  • Fax: 252-249-2275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0200684
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: