Provider Demographics
NPI:1174080352
Name:VAN COPPENOLLE, KALLIE DANIELE
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:DANIELE
Last Name:VAN COPPENOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 OPAL CT
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4147
Mailing Address - Country:US
Mailing Address - Phone:330-780-1369
Mailing Address - Fax:
Practice Address - Street 1:339 OPAL CT
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4147
Practice Address - Country:US
Practice Address - Phone:330-780-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer