Healthcare Provider Details

I. General information

NPI: 1265940969
Provider Name (Legal Business Name): NICOLE L KOCH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3565 ROUTE 611 STE 300
BARTONSVILLE PA
18321-7832
US

IV. Provider business mailing address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 272-212-0105
  • Fax: 833-222-9417
Mailing address:
  • Phone: 484-526-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP018424
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: