Healthcare Provider Details

I. General information

NPI: 1710279872
Provider Name (Legal Business Name): ALISHA RENAE KOCH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S CLARK AVE
LYONS KS
67554-3003
US

IV. Provider business mailing address

619 S CLARK AVE P.O. BOX 828
LYONS KS
67554-3003
US

V. Phone/Fax

Practice location:
  • Phone: 620-257-7150
  • Fax:
Mailing address:
  • Phone: 620-257-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1496664061
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: