Healthcare Provider Details

I. General information

NPI: 1457456212
Provider Name (Legal Business Name): SARAH KOOIENGA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N 22ND ST, UNIT A
LARAMIE WY
82072-5306
US

IV. Provider business mailing address

820 EAST 17TH STREET
CHEYENNE WY
82001-4797
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5364
  • Fax:
Mailing address:
  • Phone: 307-632-2434
  • Fax: 307-634-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number34298.1347
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: