Provider Demographics
NPI:1831313014
Name:KOSS, MARY KAY (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY KAY
Middle Name:
Last Name:KOSS
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9027 ROBINDALE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1578
Mailing Address - Country:US
Mailing Address - Phone:313-531-1307
Mailing Address - Fax:313-982-8493
Practice Address - Street 1:19401 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2641
Practice Address - Country:US
Practice Address - Phone:313-982-8192
Practice Address - Fax:313-982-8493
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR416222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2202140337015Medicare ID - Type Unspecified