Provider Demographics
NPI:1407173719
Name:KOCH, KATHLEEN J (RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:KOCH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2800
Mailing Address - Country:US
Mailing Address - Phone:641-422-7000
Mailing Address - Fax:641-422-6433
Practice Address - Street 1:1000 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2800
Practice Address - Country:US
Practice Address - Phone:641-422-7000
Practice Address - Fax:641-422-6433
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01243133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered