Provider Demographics
NPI:1265620736
Name:KOOMA, VEDWATTIE D
Entity type:Individual
Prefix:
First Name:VEDWATTIE
Middle Name:D
Last Name:KOOMA
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 1:3130 BIRKHEAD DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2565
Mailing Address - Country:US
Mailing Address - Phone:210-824-1268
Mailing Address - Fax:210-824-1268
Practice Address - Street 1:3130 BIRKHEAD DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-2565
Practice Address - Country:US
Practice Address - Phone:210-824-1268
Practice Address - Fax:210-824-1268
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163458164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse