Healthcare Provider Details

I. General information

NPI: 1013245513
Provider Name (Legal Business Name): MICHELLE MARIE KOCH RN, PHN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N HOLCOMBE AVE SUITE 250
LITCHFIELD MN
55355-2210
US

IV. Provider business mailing address

114 N HOLCOMBE AVE SUITE 250
LITCHFIELD MN
55355-2210
US

V. Phone/Fax

Practice location:
  • Phone: 320-693-5370
  • Fax: 320-693-5399
Mailing address:
  • Phone: 320-693-5370
  • Fax: 320-693-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberZ986290946723
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: