Healthcare Provider Details

I. General information

NPI: 1992057749
Provider Name (Legal Business Name): MARY JANE FORREST-COSTA RN, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BARNES ST
OCEANSIDE CA
92054-3406
US

IV. Provider business mailing address

104 BARNES ST
OCEANSIDE CA
92054-3406
US

V. Phone/Fax

Practice location:
  • Phone: 760-967-4401
  • Fax:
Mailing address:
  • Phone: 760-967-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number795453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: