Provider Demographics
NPI:1629053574
Name:KOZLICAK, ELIZABETH A (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:KOZLICAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN: PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:20 WORCESTER CENTER BLVD
Practice Address - Street 2:STE 590
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-368-3179
Practice Address - Fax:508-368-3164
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA96018363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
0324736OtherMEDICAID WELFARE
NP1063OtherBLUE CARE ELECT
NP1063OtherBLUE SHIELD HMO BLUE
54954OtherFALLON COMM. HEALTH PLAN
NP1063OtherBLUE SHIELD INDEMNITY
MA0324736Medicaid
NP1063OtherMEDICARE B
AA3670OtherHARVARD PILGRIM HEALTHCAR
NP1063OtherBLUE CARE ELECT
MA0324736Medicaid