Provider Demographics
NPI:1740432228
Name:KOSAK, MISTY S (RD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:S
Last Name:KOSAK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:S
Other - Last Name:DUCHNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1800 MULBERRY STREET
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510
Mailing Address - Country:US
Mailing Address - Phone:570-703-8084
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY STREET
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510
Practice Address - Country:US
Practice Address - Phone:570-703-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006578133V00000X
PA963292133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered