| Doctor Name: | MRS. MARY BETH KOEHLER |
| NPI Number: | 1255765095 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PNP-BC |
| License Number: | 162702 |
| Business Practice Address: | 14 Doctors Cir Suite 3 Supply, NC - 284624097 |
| Business Phone Number: | 9107547075 |
| Business Fax Number: | 9107542158 |
| Mailing Address: | 14 Doctors Cir, Suite 3 SUPPLY |
| State: | NC |
| Postal Code: | 284624097 |
| Phone Number: | 9107547075 |
| Fax Number: | 9107542158 |
| NPI Enumeration Date: | 08/28/2013 |
| NPI Last Update Date: | 08/28/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0200X |
| License Number: | 162702 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Pediatrics |
| Taxonomy Definition: | |