Healthcare Provider Details

I. General information

NPI: 1669195509
Provider Name (Legal Business Name): AMANDA KOZAK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 S CEDAR CREST BLVD STE 2800
ALLENTOWN PA
18103-6230
US

IV. Provider business mailing address

2100 MACK BLVD
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-3422
  • Fax:
Mailing address:
  • Phone: 484-884-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberDN007882
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: