Provider Demographics
NPI:1265157796
Name:KOCH, EDWINA MANTE
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:MANTE
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 1:179 BERGEN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-2805
Mailing Address - Country:US
Mailing Address - Phone:201-707-0560
Mailing Address - Fax:
Practice Address - Street 1:2166 NE CLACKAMAS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1688
Practice Address - Country:US
Practice Address - Phone:201-707-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula