Healthcare Provider Details

I. General information

NPI: 1366688715
Provider Name (Legal Business Name): SUZANNE M KOCH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W10541 ARMY LANE
ATHELSTANE WI
54104
US

IV. Provider business mailing address

W10541 ARMY LANE
ATHELSTANE WI
54104
US

V. Phone/Fax

Practice location:
  • Phone: 715-927-7755
  • Fax:
Mailing address:
  • Phone: 715-927-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberWILPN#12103-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: