Provider Demographics
NPI:1902031255
Name:KOEBBE, MARY COLLEEN (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:KOEBBE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:COLLEEN
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9568 PINE SPRAY CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-2610
Mailing Address - Country:US
Mailing Address - Phone:314-842-4529
Mailing Address - Fax:
Practice Address - Street 1:9568 PINE SPRAY CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-2610
Practice Address - Country:US
Practice Address - Phone:314-842-4529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO096789163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse