Basic Information
| Provider Information | |||||||||
| NPI: | 1154318798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSMACH | ||||||||
| FirstName: | LYNNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 WOODLAND AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558032547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187285375 | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 TRETTEL LN | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188782136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R-1089282 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 911017800 | 05 | MN | MEDICAID |