Healthcare Provider Details

I. General information

NPI: 1790277788
Provider Name (Legal Business Name): SANDRA LYNN KOZLOSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRIEBLE DR STE 3
TUNKHANNOCK PA
18657-7055
US

IV. Provider business mailing address

10 TRIEBLE DR STE 3
TUNKHANNOCK PA
18657-7055
US

V. Phone/Fax

Practice location:
  • Phone: 570-996-2700
  • Fax: 570-996-2735
Mailing address:
  • Phone: 570-996-2700
  • Fax: 570-996-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN264592L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: