Provider Demographics
NPI:1992123152
Name:KOOB, JULIE ANTONETTE (LPN)
Entity type:Individual
Prefix:MISS
First Name:JULIE
Middle Name:ANTONETTE
Last Name:KOOB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 N CALLE RINCONADO
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9328
Mailing Address - Country:US
Mailing Address - Phone:520-286-5707
Mailing Address - Fax:
Practice Address - Street 1:1990 N CALLE RINCONADO
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9328
Practice Address - Country:US
Practice Address - Phone:520-286-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27069194A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse