Provider Demographics
NPI:1114743291
Name:KOCH, MACKENZIE (DNP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-1820
Mailing Address - Country:US
Mailing Address - Phone:308-991-5337
Mailing Address - Fax:
Practice Address - Street 1:102 3RD AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-7820
Practice Address - Country:US
Practice Address - Phone:308-237-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE115738363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health