Healthcare Provider Details

I. General information

NPI: 1114743291
Provider Name (Legal Business Name): MACKENZIE KOCH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2024
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 3RD AVE
KEARNEY NE
68845-7820
US

IV. Provider business mailing address

903 ARTHUR ST
HOLDREGE NE
68949-1820
US

V. Phone/Fax

Practice location:
  • Phone: 308-237-2273
  • Fax:
Mailing address:
  • Phone: 308-991-5337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number115738
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: