Provider Demographics
NPI:1114695491
Name:KOZAK, MARY ELIZABETH (CRPA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:KOZAK
Suffix:
Gender:F
Credentials:CRPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2813
Mailing Address - Country:US
Mailing Address - Phone:631-369-0104
Mailing Address - Fax:631-369-5433
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2813
Practice Address - Country:US
Practice Address - Phone:631-369-0104
Practice Address - Fax:631-369-5433
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist