Provider Demographics
NPI:1801620349
Name:KOCH, LISA ANN (FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:KOCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:588 KENYON HILL RD
Mailing Address - Street 2:
Mailing Address - City:DEPOSIT
Mailing Address - State:NY
Mailing Address - Zip Code:13754-3715
Mailing Address - Country:US
Mailing Address - Phone:607-205-5329
Mailing Address - Fax:
Practice Address - Street 1:588 KENYON HILL RD
Practice Address - Street 2:
Practice Address - City:DEPOSIT
Practice Address - State:NY
Practice Address - Zip Code:13754-3715
Practice Address - Country:US
Practice Address - Phone:607-205-5329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY677039163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse