Healthcare Provider Details

I. General information

NPI: 1154355121
Provider Name (Legal Business Name): TRACY L KOZAK AP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/07/2020
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PASEO REYES DR
ST AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

260 PASEO REYES DR
SAINT AUGUSTINE FL
32095-8462
US

V. Phone/Fax

Practice location:
  • Phone: 904-806-3441
  • Fax: 904-592-5370
Mailing address:
  • Phone: 904-806-3441
  • Fax: 904-592-5370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 1598
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: