Provider Demographics
NPI:1376933630
Name:KOSSAKOWSKI, KIM
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:KOSSAKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIM
Other - Middle Name:ELIZABETH
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:4266 SUNBEAM RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2425
Mailing Address - Country:US
Mailing Address - Phone:904-268-5200
Mailing Address - Fax:904-407-6007
Practice Address - Street 1:4266 SUNBEAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2425
Practice Address - Country:US
Practice Address - Phone:904-268-5200
Practice Address - Fax:904-407-6007
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3025202363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care