Provider Demographics
NPI:1710528880
Name:KOZLOVA, SVETLANA
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:KOZLOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 MCCORMICK RD, EXECUTIVE PLAZA 1
Mailing Address - Street 2:SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1070
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3865
Practice Address - Country:US
Practice Address - Phone:770-297-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN252782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily