Provider Demographics
NPI:1336656537
Name:KOCH, VICTORIA (APRN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955860
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-1048
Mailing Address - Country:US
Mailing Address - Phone:636-498-5944
Mailing Address - Fax:618-443-1383
Practice Address - Street 1:602 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6264
Practice Address - Country:US
Practice Address - Phone:618-899-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016821363L00000X
MO2017038330363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner