Healthcare Provider Details

I. General information

NPI: 1558984120
Provider Name (Legal Business Name): KATHERINE COSCA ROY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 OLD NEWPORT BLVD
NEWPORT BEACH CA
92663-4211
US

IV. Provider business mailing address

238 MARSALA
NEWPORT BEACH CA
92660-8308
US

V. Phone/Fax

Practice location:
  • Phone: 949-287-6880
  • Fax:
Mailing address:
  • Phone: 949-432-1744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: