Healthcare Provider Details

I. General information

NPI: 1679769442
Provider Name (Legal Business Name): CARLA COZAD LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 W HOOD PL SUITE 102
KENNEWICK WA
99336-6714
US

IV. Provider business mailing address

7105 W HOOD PL SUITE 102
KENNEWICK WA
99336-6714
US

V. Phone/Fax

Practice location:
  • Phone: 509-374-4719
  • Fax: 509-374-3873
Mailing address:
  • Phone: 509-374-4719
  • Fax: 509-374-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00024519
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: