Healthcare Provider Details

I. General information

NPI: 1588051775
Provider Name (Legal Business Name): CORINNE MARY KOCH-BLAYDON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 04/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 OAK GROVE RD
OTTSVILLE PA
18942-9748
US

IV. Provider business mailing address

57 OAK GROVE RD
OTTSVILLE PA
18942-9748
US

V. Phone/Fax

Practice location:
  • Phone: 610-751-8358
  • Fax:
Mailing address:
  • Phone: 610-751-8358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP014883
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: