Provider Demographics
NPI:1952951568
Name:KOSULANDICH, MARYLYNN
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:
Last Name:KOSULANDICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYN
Other - Middle Name:
Other - Last Name:KOSULANDICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:638 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-9742
Mailing Address - Country:US
Mailing Address - Phone:707-677-0977
Mailing Address - Fax:
Practice Address - Street 1:638 3RD AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CA
Practice Address - Zip Code:95570-9742
Practice Address - Country:US
Practice Address - Phone:707-677-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider