Individual
ELLISE SUZANNE KOENN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
10228 DUPONT CIRCLE DR E STE 100, FORT WAYNE, IN 46825-1611
(260) 222-7401
(260) 209-5956
Mailing address
PO BOX 772437, DETROIT, MI 48277-2437
(317) 575-7304
(317) 575-7333
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
APRN.CNP.023023
OH
363LF0000X
Family Nurse Practitioner
Primary
71012516A
IN
Other
Enumeration date
07/02/2018
Last updated
02/01/2023
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