Healthcare Provider Details

I. General information

NPI: 1184113078
Provider Name (Legal Business Name): MARY JO KOZEL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 WEST BELVEDERE
BALTIMORE MD
21215
US

IV. Provider business mailing address

6414 BLENHEIM RD
BALTIMORE MD
21212-1717
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-7776
  • Fax:
Mailing address:
  • Phone: 816-209-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR200618
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: