Basic Information
| Provider Information | |||||||||
| NPI: | 1700831542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOEHLER | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEEBERGER | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | V | ||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286598 | ||||||||
| FaxNumber: | 4103283577 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286598 | ||||||||
| FaxNumber: | 4103283577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R145838 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 640729-01 | 01 | MD | BC/BS | OTHER | 404708700 | 05 | MD | MEDICAID |