Healthcare Provider Details

I. General information

NPI: 1619790391
Provider Name (Legal Business Name): KELLY JEAN KOCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

650 S GAINES ST APT 511
PORTLAND OR
97239-4767
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 503-403-8393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10018499
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: