Provider Demographics
NPI:1164280731
Name:KOZAK, SHANNON (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 RYE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3659
Mailing Address - Country:US
Mailing Address - Phone:585-507-8940
Mailing Address - Fax:
Practice Address - Street 1:3300 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3741
Practice Address - Country:US
Practice Address - Phone:585-865-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY711501163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator