Healthcare Provider Details

I. General information

NPI: 1265898159
Provider Name (Legal Business Name): MRS. STEPHANIE KOZACKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE FITZGERALD

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FULLER ST
ALEXANDRIA BAY NY
13607-1316
US

IV. Provider business mailing address

4 FULLER ST
ALEXANDRIA BAY NY
13607-1316
US

V. Phone/Fax

Practice location:
  • Phone: 315-482-1277
  • Fax:
Mailing address:
  • Phone: 315-482-1277
  • Fax: 315-482-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number113383
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: