Healthcare Provider Details

I. General information

NPI: 1649657750
Provider Name (Legal Business Name): ALICIA KOCH-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14826 42ND AVE S
TUKWILA WA
98168-4436
US

IV. Provider business mailing address

14826 42ND AVE S
TUKWILA WA
98168-4436
US

V. Phone/Fax

Practice location:
  • Phone: 206-795-8307
  • Fax:
Mailing address:
  • Phone: 206-795-8307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberOC60562527
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: