MEDICARE: CAROLANN ROBERTA KOHTZ RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	2015026975	MO

General Provider Information

NPI Number	:	1649979881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLANN ROBERTA KOHTZ RN

Provider Business Mailing Address
First Line	:	1107 MISSISSIPPI AVE APT 305
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2461
Country	:	US
Telephone Number	:	309-338-4510
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 MISSISSIPPI AVE APT 305
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2461
Country	:	US
Telephone Number	:	309-338-4510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2023
Last Update Date	:	02/27/2023

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