Provider Demographics
NPI:1285358002
Name:KOZLOWSKI, BRANDONE NICCOLE (DTR)
Entity type:Individual
Prefix:
First Name:BRANDONE
Middle Name:NICCOLE
Last Name:KOZLOWSKI
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:NICCOLE
Other - Last Name:KOZLOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DTR
Mailing Address - Street 1:75 MOUNT RAINIER DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1047
Mailing Address - Country:US
Mailing Address - Phone:415-728-2478
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST BLDG 203
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1563
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered