Healthcare Provider Details

I. General information

NPI: 1508100132
Provider Name (Legal Business Name): MOLLY JEAN KOCZARSKI MOLLY KOCZARSKI, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY JEAN MAXFIELD MOLLY MAXFIELD, RD

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 BARNES BLVD
JOINT BASE LEWIS MCCHORD WA
98438-1303
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 360-580-5423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number60083621
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: