Healthcare Provider Details

I. General information

NPI: 1376933630
Provider Name (Legal Business Name): MRS. KIM KOSSAKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM ELIZABETH BENNETT ARNP

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 SUNBEAM RD
JACKSONVILLE FL
32257-2425
US

IV. Provider business mailing address

4266 SUNBEAM RD
JACKSONVILLE FL
32257-2425
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-5200
  • Fax: 904-407-6007
Mailing address:
  • Phone: 904-268-5200
  • Fax: 904-407-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberARNP 3025202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: