Healthcare Provider Details

I. General information

NPI: 1255716825
Provider Name (Legal Business Name): KELLIE KOZAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E EVESHAM RD STE 201
VOORHEES NJ
08043-1437
US

IV. Provider business mailing address

1001 SHEPPARD RD
VOORHEES NJ
08043-4796
US

V. Phone/Fax

Practice location:
  • Phone: 856-565-2900
  • Fax: 856-565-2901
Mailing address:
  • Phone: 817-946-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066072
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00883700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: