Healthcare Provider Details

I. General information

NPI: 1558782698
Provider Name (Legal Business Name): MARY KOZUCH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10831 FOREST PINES DR STE 100
RALEIGH NC
27614-8077
US

IV. Provider business mailing address

2000 PERIMETER PARK DR STE 200
MORRISVILLE NC
27560-8442
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-5273
  • Fax: 919-781-8853
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5006682
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: