Basic Information
| Provider Information | |||||||||
| NPI: | 1730124579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOZAK | ||||||||
| FirstName: | RENATA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 HUNTINGRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606335991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 GRISWOLD ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602245267 | ||||||||
| FaxNumber: | 8602245752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | 002026 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2190118 | 01 | CIGNA | OTHER |