Healthcare Provider Details

I. General information

NPI: 1790837193
Provider Name (Legal Business Name): MARIE KOPTA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 WEHRLE DR
WILLIAMSVILLE NY
14221-7037
US

IV. Provider business mailing address

PO BOX 464
RIPLEY NY
14775-0464
US

V. Phone/Fax

Practice location:
  • Phone: 716-276-2123
  • Fax: 716-276-2129
Mailing address:
  • Phone: 716-736-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number245818
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: