Healthcare Provider Details

I. General information

NPI: 1043463680
Provider Name (Legal Business Name): MRS. NICOLE KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 CONNECTICUT AVE STE 606
KENSINGTON MD
20895-3910
US

IV. Provider business mailing address

2415 MUSGROVE RD 3105
SILVER SPRING MD
20904-5202
US

V. Phone/Fax

Practice location:
  • Phone: 301-942-2212
  • Fax: 301-917-6501
Mailing address:
  • Phone: 301-989-0193
  • Fax: 301-879-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0003886
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: