Provider Demographics
NPI:1598445512
Name:KOZISCHEK, COURTNEY LEIGH (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEIGH
Last Name:KOZISCHEK
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:400 US 70 HIGHWAY E
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4049
Practice Address - Country:US
Practice Address - Phone:919-235-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007412133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598445512Medicaid