Provider Demographics
NPI:1104107036
Name:KOSKO, MAMIE M (NP)
Entity type:Individual
Prefix:MRS
First Name:MAMIE
Middle Name:M
Last Name:KOSKO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 WILBURN WAY
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3692
Mailing Address - Country:US
Mailing Address - Phone:662-320-4008
Mailing Address - Fax:662-320-2450
Practice Address - Street 1:100 WILBURN WAY
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3692
Practice Address - Country:US
Practice Address - Phone:662-320-4008
Practice Address - Fax:662-320-2450
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05676593Medicaid