Healthcare Provider Details

I. General information

NPI: 1821034281
Provider Name (Legal Business Name): ANDREA E KOCH WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA BROCKBERG

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 HIGHWAY 55
PLYMOUTH MN
55441-6100
US

IV. Provider business mailing address

10700 HIGHWAY 55
PLYMOUTH MN
55441-6100
US

V. Phone/Fax

Practice location:
  • Phone: 952-213-2144
  • Fax: 952-213-2184
Mailing address:
  • Phone: 952-213-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR1697315
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2910
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: