Healthcare Provider Details

I. General information

NPI: 1497053714
Provider Name (Legal Business Name): SHANNA D. KOZAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PARK STREET
BOWLING GREEN KY
42101-1780
US

IV. Provider business mailing address

250 PARK STREET
BOWLING GREEN KY
42101-1780
US

V. Phone/Fax

Practice location:
  • Phone: 270-796-6540
  • Fax: 270-796-6576
Mailing address:
  • Phone: 270-796-6540
  • Fax: 270-796-6576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number15685
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3006749
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3006749
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: