Healthcare Provider Details

I. General information

NPI: 1235794249
Provider Name (Legal Business Name): LYNSEY KOCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W BUCHANAN ST
CLARKSVILLE AR
72830-2252
US

IV. Provider business mailing address

1000 W BUCHANAN ST
CLARKSVILLE AR
72830-2252
US

V. Phone/Fax

Practice location:
  • Phone: 479-754-6210
  • Fax: 800-354-2182
Mailing address:
  • Phone: 479-754-6210
  • Fax: 800-354-2182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR093530
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: