Provider Demographics
NPI:1841180429
Name:FUDGE, COZETTA C (SOLE CARE PROVIDER)
Entity type:Individual
Prefix:MISS
First Name:COZETTA
Middle Name:C
Last Name:FUDGE
Suffix:
Gender:F
Credentials:SOLE CARE PROVIDER
Other - Prefix:MISS
Other - First Name:COZETTA
Other - Middle Name:C
Other - Last Name:FUDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SOLE CARE PROVIDER
Mailing Address - Street 1:4672 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-1467
Mailing Address - Country:US
Mailing Address - Phone:402-312-7934
Mailing Address - Fax:
Practice Address - Street 1:4672 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-1467
Practice Address - Country:US
Practice Address - Phone:402-312-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEG011742123747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty