Provider Demographics
NPI:1477508075
Name:KOZAK, BRENDA KAUFFMAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAUFFMAN
Last Name:KOZAK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:S
Other - Last Name:KAUFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 KEISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610
Mailing Address - Country:US
Mailing Address - Phone:610-685-8500
Mailing Address - Fax:610-685-4833
Practice Address - Street 1:2605 KEISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610
Practice Address - Country:US
Practice Address - Phone:610-685-8500
Practice Address - Fax:610-685-4833
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009049363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101599590 0001Medicaid
PA101599590 0001Medicaid
101530FJEMedicare PIN