Provider Demographics
NPI:1962182204
Name:KOEKEBACKER, NICOLE CECILE (MAT, MS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CECILE
Last Name:KOEKEBACKER
Suffix:
Gender:F
Credentials:MAT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2717
Mailing Address - Country:US
Mailing Address - Phone:607-753-5106
Mailing Address - Fax:
Practice Address - Street 1:60 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2717
Practice Address - Country:US
Practice Address - Phone:607-753-5106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator