Provider Demographics
NPI:1376313148
Name:KOCH, AMANDA ANN (CPRS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:KOCH
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 5TH AVE NE APT 204
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0475
Mailing Address - Country:US
Mailing Address - Phone:320-360-6004
Mailing Address - Fax:
Practice Address - Street 1:210 5TH AVE NE APT 204
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0475
Practice Address - Country:US
Practice Address - Phone:320-360-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist