Provider Demographics
NPI:1558701052
Name:KOCH, CHRISTIE ANN (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:ANN
Last Name:KOCH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:ANN
Other - Last Name:MANCIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:530 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1150
Mailing Address - Country:US
Mailing Address - Phone:715-582-0272
Mailing Address - Fax:
Practice Address - Street 1:530 MEADOW LN
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1150
Practice Address - Country:US
Practice Address - Phone:715-582-0272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI175768-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse