Provider Demographics
NPI:1316240674
Name:KOOIMA, MARISA JO (ARNP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:JO
Last Name:KOOIMA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:KOOIMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:200 S BIRCH RD APT 1209
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1537
Mailing Address - Country:US
Mailing Address - Phone:954-629-2240
Mailing Address - Fax:
Practice Address - Street 1:200 S BIRCH RD APT 1209
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1537
Practice Address - Country:US
Practice Address - Phone:954-629-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9246107363LA2200X
FLAPRN9246107363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592202OtherWELLCARE
FLP988384OtherFREEDOM HEALTH
FLY06HOOtherBCBS OF FL
FLP932403OtherOPTIMUM
FL003103900Medicaid
FLY06H0OtherBLUE CROSS BLUE SHIELD