Provider Demographics
NPI:1851677975
Name:KOCH, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GARNER RD
Mailing Address - Street 2:APT C-4
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018-9509
Mailing Address - Country:US
Mailing Address - Phone:518-274-6525
Mailing Address - Fax:518-274-6511
Practice Address - Street 1:1 CONWAY CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2108
Practice Address - Country:US
Practice Address - Phone:518-274-6525
Practice Address - Fax:518-274-6511
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206566164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse