Healthcare Provider Details

I. General information

NPI: 1568232007
Provider Name (Legal Business Name): JOHN JOSEPH KOZLOWSKI IV FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15044 220TH AVE
BIG RAPIDS MI
49307-9248
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-527-7150
  • Fax: 231-796-4109
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704355710
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: