Provider Demographics
NPI:1053898114
Name:KOCH, MARRIE
Entity type:Individual
Prefix:
First Name:MARRIE
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 OLD CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:PONCE INLET
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6910
Mailing Address - Country:US
Mailing Address - Phone:502-417-1637
Mailing Address - Fax:
Practice Address - Street 1:112 OLD CARRIAGE RD
Practice Address - Street 2:
Practice Address - City:PONCE INLET
Practice Address - State:FL
Practice Address - Zip Code:32127-6910
Practice Address - Country:US
Practice Address - Phone:502-417-1637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN441736163W00000X
FLF06220492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse