Provider Demographics
NPI:1790361947
Name:COZZENS, KIMBERLY ANNE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:COZZENS
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 1:344 E 100 S STE 301
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1727
Mailing Address - Country:US
Mailing Address - Phone:801-428-4257
Mailing Address - Fax:
Practice Address - Street 1:237 DEERHOLLOW CIR
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-3019
Practice Address - Country:US
Practice Address - Phone:385-489-9665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0712323892Medicaid