Provider Demographics
NPI:1598712960
Name:KOCH, THERESE K (MSW, CNN, APRN-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:K
Last Name:KOCH
Suffix:
Gender:F
Credentials:MSW, CNN, APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BON AIR DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1867
Mailing Address - Country:US
Mailing Address - Phone:856-596-2053
Mailing Address - Fax:
Practice Address - Street 1:201 LAUREL OAK RD
Practice Address - Street 2:SUITE B
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4424
Practice Address - Country:US
Practice Address - Phone:856-566-5478
Practice Address - Fax:856-566-9561
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00040100363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0013234Medicaid
NJ0700098SZQMedicare ID - Type Unspecified
NJP90298Medicare UPIN