Provider Demographics
NPI:1841518545
Name:KOCH, HAZEL YVETTE (DA)
Entity type:Individual
Prefix:MRS
First Name:HAZEL
Middle Name:YVETTE
Last Name:KOCH
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WATERMAN STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-864-5453
Mailing Address - Fax:
Practice Address - Street 1:148 WATERMAN STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-864-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00350171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist