Provider Demographics
NPI:1174567556
Name:KOEPP, SUSAN DIANE (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:KOEPP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:1101 BROAD ST EXT
Mailing Address - City:ORIENTAL
Mailing Address - State:NC
Mailing Address - Zip Code:28571-9790
Mailing Address - Country:US
Mailing Address - Phone:252-249-2220
Mailing Address - Fax:252-249-2275
Practice Address - Street 1:1101 BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:ORIENTAL
Practice Address - State:NC
Practice Address - Zip Code:28571-9790
Practice Address - Country:US
Practice Address - Phone:252-249-2220
Practice Address - Fax:252-249-2275
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0200684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily