Provider Demographics
NPI:1104378744
Name:KOZAK, BRENDA JEAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:KOZAK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ELON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-2536
Mailing Address - Country:US
Mailing Address - Phone:434-929-1400
Mailing Address - Fax:434-455-2487
Practice Address - Street 1:134 ELON RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-2536
Practice Address - Country:US
Practice Address - Phone:434-929-1400
Practice Address - Fax:434-455-2487
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily