Healthcare Provider Details

I. General information

NPI: 1386215390
Provider Name (Legal Business Name): NICOLE KOZLAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 09/26/2022
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8063
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8063
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3899
  • Fax: 860-676-3476
Mailing address:
  • Phone: 860-679-3899
  • Fax: 860-676-3476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5292
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: