Healthcare Provider Details

I. General information

NPI: 1326477175
Provider Name (Legal Business Name): MICHELLE THERESA KOCH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

350 ENGLE ST
ENGLEWOOD NJ
07631-1808
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3449
  • Fax:
Mailing address:
  • Phone: 201-894-3449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00597500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF338142-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: