Provider Demographics
NPI:1114434255
Name:KOCH, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
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 1:1041 KIRKPATRICK RD STE 150
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8068
Mailing Address - Country:US
Mailing Address - Phone:336-890-3390
Mailing Address - Fax:336-890-3391
Practice Address - Street 1:1041 KIRKPATRICK RD STE 150
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8068
Practice Address - Country:US
Practice Address - Phone:336-890-3390
Practice Address - Fax:336-890-3391
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1500363A00000X
NC001017795363A00000X
NC0010-07795363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant