Provider Demographics
NPI:1255863767
Name:KOSICEK, CARMEN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:KOSICEK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7426 N LA CHOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2306
Mailing Address - Country:US
Mailing Address - Phone:503-755-6703
Mailing Address - Fax:503-755-6704
Practice Address - Street 1:535 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4142
Practice Address - Country:US
Practice Address - Phone:503-755-6703
Practice Address - Fax:503-755-6704
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201803794163W00000X
AZ233893163W00000X, 363LP0808X
WI221711163W00000X, 363LP0808X
IAG168938363LP0808X
WI7619363LP0808X
OR201803795NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse