Healthcare Provider Details

I. General information

NPI: 1265157796
Provider Name (Legal Business Name): EDWINA MANTE KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 12/03/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 NE CLACKAMAS ST
PORTLAND OR
97232-1688
US

IV. Provider business mailing address

179 BERGEN AVE
NEW MILFORD NJ
07646-2805
US

V. Phone/Fax

Practice location:
  • Phone: 201-707-0560
  • Fax:
Mailing address:
  • Phone: 201-707-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: