Provider Demographics
NPI:1366039331
Name:KOSACK, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KOSACK
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 1:1911 SWEETBRIAR RD
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19067-3564
Mailing Address - Country:US
Mailing Address - Phone:201-270-9695
Mailing Address - Fax:
Practice Address - Street 1:1911 SWEETBRIAR RD
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:PA
Practice Address - Zip Code:19067-3564
Practice Address - Country:US
Practice Address - Phone:201-270-9695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01086300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health