Provider Demographics
NPI:1245638600
Name:KOCH, TERI (MSN, RN, FNP-BC)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:BORYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, FNP-BC
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:3283 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5054
Practice Address - Country:US
Practice Address - Phone:219-764-8439
Practice Address - Fax:219-764-8463
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005281A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily