Healthcare Provider Details

I. General information

NPI: 1215650288
Provider Name (Legal Business Name): HALEY KOZMINSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3593 MEDINA RD # 181
MEDINA OH
44256-8182
US

IV. Provider business mailing address

3567 RESERVE COMMONS DR STE 100
MEDINA OH
44256-5344
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax:
Mailing address:
  • Phone: 330-536-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0032324
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: