Provider Demographics
NPI:1235720434
Name:KOSMALA, DORIA HELEN
Entity Type:Individual
Prefix:
First Name:DORIA
Middle Name:HELEN
Last Name:KOSMALA
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 1:2125 VALLEYGATE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3753
Mailing Address - Country:US
Mailing Address - Phone:910-920-1450
Mailing Address - Fax:
Practice Address - Street 1:2125 VALLEYGATE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3754
Practice Address - Country:US
Practice Address - Phone:910-920-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-30
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-11914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program