Provider Demographics
NPI:1124055686
Name:KOLLER, MARY JO (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:KOLLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:504 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:706-235-3855
Practice Address - Fax:706-290-2721
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218765363L00000X
KY3002576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400031866Medicare PIN
KY000000068212OtherANTHEM PIN
KY50031229OtherPASSPORT- CARDIOTHORACIC SURGERY OF LOUISVILLE
1271832Medicare ID - Type Unspecified
IN200218450AMedicaid
KYS62386Medicare UPIN
KY500017880Medicare PIN
KY78008034Medicaid