Healthcare Provider Details

I. General information

NPI: 1558356113
Provider Name (Legal Business Name): MARISSA KOCH WHNP, RNC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE SW
BOLLING AFB DC
20032
US

IV. Provider business mailing address

7865 GODOLPHIN DR
SPRINGFIELD VA
22153-3308
US

V. Phone/Fax

Practice location:
  • Phone: 703-681-6196
  • Fax:
Mailing address:
  • Phone: 703-455-3536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number418533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: