Basic Information
Provider Information
NPI: 1003299819
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOEHN
FirstName: BRENDA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1371
Address2:  
City: EVANSVILLE
State: WY
PostalCode: 826361371
CountryCode: US
TelephoneNumber: 3077971307
FaxNumber: 3072320411
Practice Location
Address1: 1020 RIO VISTA
Address2:  
City: EVANSVILLE
State: WY
PostalCode: 826361307
CountryCode: US
TelephoneNumber: 3077971307
FaxNumber: 3072320411
Other Information
ProviderEnumerationDate: 06/30/2015
LastUpdateDate: 06/30/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
172V00000X  N Other Service ProvidersCommunity Health Worker 
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


Home