Healthcare Provider Details

I. General information

NPI: 1316190556
Provider Name (Legal Business Name): ANITA R. KOCH RN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7067 TIFFANY BLVD SUITE 230
POLAND OH
44514-1993
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD SUITE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-2748
  • Fax: 330-758-3282
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN. 226436
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberNS09826
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: