Healthcare Provider Details

I. General information

NPI: 1740359512
Provider Name (Legal Business Name): NICOLE KOZAK VU RN, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE VU RN, CPNP-AC

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE C300J
DALLAS TX
75230-2604
US

IV. Provider business mailing address

7777 FOREST LN STE C300J
DALLAS TX
75230-2604
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-2043
  • Fax: 972-566-7437
Mailing address:
  • Phone: 972-566-2043
  • Fax: 972-566-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number734058
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP115114
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAP115114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: