Healthcare Provider Details

I. General information

NPI: 1508224619
Provider Name (Legal Business Name): STACEY KOCH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 WHITTINGTON PKWY SUITE 100
LOUISVILLE KY
40222-4930
US

IV. Provider business mailing address

140 WHITTINGTON PKWY SUITE 100
LOUISVILLE KY
40222-4930
US

V. Phone/Fax

Practice location:
  • Phone: 502-327-9100
  • Fax: 800-632-8329
Mailing address:
  • Phone: 502-327-9100
  • Fax: 800-632-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010031
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: