Provider Demographics
NPI:1508166547
Name:KOZUB, KATRINA M (FNP)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:KOZUB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6375 US HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5217
Mailing Address - Country:US
Mailing Address - Phone:219-762-3196
Mailing Address - Fax:219-763-6438
Practice Address - Street 1:6375 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5217
Practice Address - Country:US
Practice Address - Phone:219-762-3196
Practice Address - Fax:219-763-6438
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003431A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201059470Medicaid