Provider Demographics
NPI:1730337742
Name:KOEHOORN, KAYE
Entity type:Individual
Prefix:
First Name:KAYE
Middle Name:
Last Name:KOEHOORN
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 1:429 CARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2115
Mailing Address - Country:US
Mailing Address - Phone:920-210-9765
Mailing Address - Fax:
Practice Address - Street 1:429 CARRINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2115
Practice Address - Country:US
Practice Address - Phone:920-210-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38344900163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse