Healthcare Provider Details

I. General information

NPI: 1629417894
Provider Name (Legal Business Name): MADELYN PAULA KOZUB RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

H100 SANTA MARGARITA ROAD NAVAL HOSPITAL CAMP PENDLETON
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

H100 SANTA MARGARITA ROAD NAVAL HOSPITAL CAMP PENDLETON
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-8643
  • Fax:
Mailing address:
  • Phone: 760-763-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN353991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: