Healthcare Provider Details

I. General information

NPI: 1700574258
Provider Name (Legal Business Name): HAYLEY COSTAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 02/20/2024
Certification Date: 01/03/2024
Deactivation Date: 04/24/2023
Reactivation Date: 12/29/2023

III. Provider practice location address

3137 STRATHMORE DR
VENTURA CA
93003-4833
US

IV. Provider business mailing address

1000 TOWN CENTER DR STE 300
OXNARD CA
93036-1117
US

V. Phone/Fax

Practice location:
  • Phone: 219-508-2634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: