Provider Demographics
NPI:1649657750
Name:KOCH-JOHNSON, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:KOCH-JOHNSON
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 1:14826 42ND AVE S
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-4436
Mailing Address - Country:US
Mailing Address - Phone:206-795-8307
Mailing Address - Fax:
Practice Address - Street 1:14826 42ND AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-4436
Practice Address - Country:US
Practice Address - Phone:206-795-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60562527305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service