MEDICARE: MRS. ERIN R COSTANZO APRN FNPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN146776NP	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649244997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ERIN R COSTANZO APRN FNPC

Provider Business Mailing Address
First Line	:	PO BOX 608
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180
Country	:	US
Telephone Number	:	770-459-4411
Fax Number	:	770-459-2424

Provider Business Practice Location Address
First Line	:	7869 VILLA RICA HWY
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157
Country	:	US
Telephone Number	:	770-459-4411
Fax Number	:	770-459-2424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	01/19/2010

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