Healthcare Provider Details

I. General information

NPI: 1992504740
Provider Name (Legal Business Name): EDI KOFFI ANTHONY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 S 96TH ST
OMAHA NE
68127-1259
US

IV. Provider business mailing address

6623 N 102ND AVE
OMAHA NE
68122-3018
US

V. Phone/Fax

Practice location:
  • Phone: 531-466-1275
  • Fax: 531-242-4429
Mailing address:
  • Phone: 402-981-1920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number69402
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: