Basic Information
| Provider Information | |||||||||
| NPI: | 1467563023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOEPKE | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | VELMA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 NE MULBERRY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LEE'S SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640864533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163894137 | ||||||||
| FaxNumber: | 8163894140 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363867222 | ||||||||
| FaxNumber: | 6363867810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 094885 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 912719150 | 05 | MO | MEDICAID |