Healthcare Provider Details

I. General information

NPI: 1124252325
Provider Name (Legal Business Name): GINA LORRAINE KOCH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LACEY ST
CAPE GIRARDEAU MO
63701-5230
US

IV. Provider business mailing address

1701 LACEY ST
CAPE GIRARDEAU MO
63701-5230
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-4822
  • Fax:
Mailing address:
  • Phone: 573-334-4822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2003001857
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: