Healthcare Provider Details

I. General information

NPI: 1396243762
Provider Name (Legal Business Name): GRACE MIKHAILA KOZIK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 VILLAGE RD LITTLE RIVERS HEALTH CARE -EAST CORINTH
EAST CORINTH VT
05040
US

IV. Provider business mailing address

PO BOX 338
BRADFORD VT
05033-0338
US

V. Phone/Fax

Practice location:
  • Phone: 802-439-5321
  • Fax:
Mailing address:
  • Phone: 802-222-3026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2314177
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0134241
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number076421-23
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0134241
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: