Healthcare Provider Details

I. General information

NPI: 1215523915
Provider Name (Legal Business Name): SALLY HAINES KOCH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 PETER JEFFERSON PKWY STE 300
CHARLOTTESVILLE VA
22911-8618
US

IV. Provider business mailing address

103 BAYLOR PL
CHARLOTTESVILLE VA
22902-6096
US

V. Phone/Fax

Practice location:
  • Phone: 434-817-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179671
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: