1477508075 NPI number — MRS. BRENDA KAUFFMAN KOZAK CRNP

Table of content: MRS. BRENDA KAUFFMAN KOZAK CRNP (NPI 1477508075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477508075 NPI number — MRS. BRENDA KAUFFMAN KOZAK CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOZAK
Provider First Name:
BRENDA
Provider Middle Name:
KAUFFMAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAUFFMAN
Provider Other First Name:
BRENDA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477508075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2605 KEISER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYOMISSING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-685-8500
Provider Business Mailing Address Fax Number:
610-685-4833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 KEISER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYOMISSING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-685-8500
Provider Business Practice Location Address Fax Number:
610-685-4833
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  SP009049 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101599590 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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