Provider Demographics
NPI:1023576147
Name:KOSBAB, EMMA LYNN
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LYNN
Last Name:KOSBAB
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 1:72 S ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1624
Mailing Address - Country:US
Mailing Address - Phone:435-230-5622
Mailing Address - Fax:
Practice Address - Street 1:72 S ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-1624
Practice Address - Country:US
Practice Address - Phone:435-230-5622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program