Provider Demographics
NPI:1649791617
Name:KOZAK, TANYA ELISE
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:ELISE
Last Name:KOZAK
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 1:3219 ALTURA AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3392
Mailing Address - Country:US
Mailing Address - Phone:818-812-8666
Mailing Address - Fax:
Practice Address - Street 1:2500 E FOOTHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-7102
Practice Address - Country:US
Practice Address - Phone:626-993-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program