Healthcare Provider Details

I. General information

NPI: 1376313148
Provider Name (Legal Business Name): AMANDA ANN KOCH CPRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 5TH AVE NE APT 204
SAINT CLOUD MN
56304-0475
US

IV. Provider business mailing address

210 5TH AVE NE APT 204
SAINT CLOUD MN
56304-0475
US

V. Phone/Fax

Practice location:
  • Phone: 320-360-6004
  • Fax:
Mailing address:
  • Phone: 320-360-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: