Healthcare Provider Details

I. General information

NPI: 1396432704
Provider Name (Legal Business Name): DANIELLE ELIZABETH KOZICZKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4935 S 76TH ST
GREENFIELD WI
53220-9900
US

IV. Provider business mailing address

1851 BLACKFOOT AVE
GRAFTON WI
53024-9303
US

V. Phone/Fax

Practice location:
  • Phone: 414-777-3100
  • Fax:
Mailing address:
  • Phone: 262-305-3285
  • Fax: 414-260-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8060
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: