Basic Information
| Provider Information | |||||||||
| NPI: | 1790361947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COZZENS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 344 E 100 S STE 301 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014284257 | ||||||||
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| Practice Location | |||||||||
| Address1: | 237 DEERHOLLOW CIR | ||||||||
| Address2: | |||||||||
| City: | NORTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840543019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3854899665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2021 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0712323892 | 05 | UT | MEDICAID |