Provider Demographics
NPI:1861276800
Name:KOZIL, MELONICA LUANNE LACSAMANA
Entity type:Individual
Prefix:
First Name:MELONICA LUANNE
Middle Name:LACSAMANA
Last Name:KOZIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELONICA
Other - Middle Name:LACSAMANA
Other - Last Name:LECAROZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 STANFORD PL
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-8001
Mailing Address - Country:US
Mailing Address - Phone:847-373-4540
Mailing Address - Fax:
Practice Address - Street 1:2101 STANFORD PL
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-8001
Practice Address - Country:US
Practice Address - Phone:847-373-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program