Provider Demographics
NPI:1194580480
Name:KOETZNER, KELSEY RAFFAELA (FNP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAFFAELA
Last Name:KOETZNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CAROLYN CT
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1551
Mailing Address - Country:US
Mailing Address - Phone:516-993-7005
Mailing Address - Fax:
Practice Address - Street 1:152 N WELLWOOD AVE STE 3
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4091
Practice Address - Country:US
Practice Address - Phone:631-226-4342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353370-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily