Healthcare Provider Details

I. General information

NPI: 1932672276
Provider Name (Legal Business Name): EMILY N KOZAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 N BELL SCHOOL RD
ROCKFORD IL
61114-6624
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-0300
  • Fax: 815-639-9345
Mailing address:
  • Phone: 779-696-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017919
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: