Provider Demographics
NPI:1235794249
Name:KOCH, LYNSEY (RN)
Entity Type:Individual
Prefix:
First Name:LYNSEY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-2252
Mailing Address - Country:US
Mailing Address - Phone:479-754-6210
Mailing Address - Fax:800-354-2182
Practice Address - Street 1:1000 W BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-2252
Practice Address - Country:US
Practice Address - Phone:479-754-6210
Practice Address - Fax:800-354-2182
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR093530163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103106724Medicaid