Provider Demographics
NPI:1669627758
Name:KOSHUBA, PATRICIA KAY (MS,RD,LD/N)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:KAY
Last Name:KOSHUBA
Suffix:
Gender:F
Credentials:MS,RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N 20TH AVE
Mailing Address - Street 2:APT 6
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4078
Mailing Address - Country:US
Mailing Address - Phone:954-922-5824
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3134133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered