Provider Demographics
NPI:1891269353
Name:KO, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:KO
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 1:576 W SIDE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1722
Mailing Address - Country:US
Mailing Address - Phone:201-850-3751
Mailing Address - Fax:
Practice Address - Street 1:10 LINK DR
Practice Address - Street 2:
Practice Address - City:ROCKLEIGH
Practice Address - State:NJ
Practice Address - Zip Code:07647-2504
Practice Address - Country:US
Practice Address - Phone:201-784-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09124800224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant