Healthcare Provider Details

I. General information

NPI: 1730124579
Provider Name (Legal Business Name): RENATA KOZAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 GRISWOLD ST
NEW BRITAIN CT
06050
US

IV. Provider business mailing address

88 HUNTINGRIDGE DR
SOUTH GLASTONBURY CT
06073
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5267
  • Fax: 860-224-5752
Mailing address:
  • Phone: 860-633-5991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number002026
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: