Provider Demographics
NPI:1497053714
Name:KOZAK, SHANNA D (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:D
Last Name:KOZAK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1780
Mailing Address - Country:US
Mailing Address - Phone:270-796-6540
Mailing Address - Fax:270-796-6576
Practice Address - Street 1:250 PARK STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1780
Practice Address - Country:US
Practice Address - Phone:270-796-6540
Practice Address - Fax:270-796-6576
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15685363LA2100X
KY3006749363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care