Healthcare Provider Details

I. General information

NPI: 1821479189
Provider Name (Legal Business Name): BRIANA KOZAK PA, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 04/03/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N GREEN BAY AVE
NORTH CHICAGO IL
60064
US

IV. Provider business mailing address

6334 ELDERWOOD CT
OAK FOREST IL
60452-1749
US

V. Phone/Fax

Practice location:
  • Phone: 708-833-9174
  • Fax:
Mailing address:
  • Phone: 708-833-9174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009992
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164006332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: