Basic Information
| Provider Information | |||||||||
| NPI: | 1780141523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOONS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 DAVIS SOUND LN | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284092090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8315242888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 PORTERS NECK RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284119196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106867195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A6850 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.