Healthcare Provider Details

I. General information

NPI: 1285489534
Provider Name (Legal Business Name): AMAYA JENN KOZUSKO MS, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMAYA JENN ABADIA-MANTHEI

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 HUSSON AVE STE 2
BANGOR ME
04401-3373
US

IV. Provider business mailing address

310 PARSONS DR APT 403
CHARLOTTESVILLE VA
22901-3224
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-2373
  • Fax:
Mailing address:
  • Phone: 781-492-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP241106
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: