Provider Demographics
NPI:1538591888
Name:KOENEN, DEANNA (ARNP)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:KOENEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E DIXIE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7601
Mailing Address - Country:US
Mailing Address - Phone:352-326-4031
Mailing Address - Fax:352-360-0257
Practice Address - Street 1:401 W NORTH BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5044
Practice Address - Country:US
Practice Address - Phone:352-728-4242
Practice Address - Fax:352-728-4868
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9167881363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010503000Medicaid