Provider Demographics
NPI:1821479189
Name:KOZAK, BRIANA (PA, RD)
Entity Type:Individual
Prefix:MS
First Name:BRIANA
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:PA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 ELDERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1749
Mailing Address - Country:US
Mailing Address - Phone:708-833-9174
Mailing Address - Fax:
Practice Address - Street 1:3001 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:708-833-9174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009992363A00000X
IL164006332133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered