Healthcare Provider Details

I. General information

NPI: 1659600468
Provider Name (Legal Business Name): TARA ELLEN KOCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST
BARABOO WI
53913-2183
US

IV. Provider business mailing address

PO BOX 29
BARABOO WI
53913-0029
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4200
  • Fax: 608-524-7990
Mailing address:
  • Phone: 608-355-4200
  • Fax: 608-524-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number133039-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: