Healthcare Provider Details

I. General information

NPI: 1346601077
Provider Name (Legal Business Name): SHANNONE KOCH APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 S BELLEVUE AVE
DOVER OH
44622-9405
US

IV. Provider business mailing address

204 S BELLEVUE AVE
DOVER OH
44622-9405
US

V. Phone/Fax

Practice location:
  • Phone: 234-801-4747
  • Fax: 234-801-4647
Mailing address:
  • Phone: 234-801-4747
  • Fax: 234-801-4647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.18753
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: