Healthcare Provider Details

I. General information

NPI: 1336799006
Provider Name (Legal Business Name): STEPHANIE ANN KOSTAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 DOCTORS ST
METTER GA
30439-3337
US

IV. Provider business mailing address

10 DOCTORS ST
METTER GA
30439-3337
US

V. Phone/Fax

Practice location:
  • Phone: 912-685-5715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN310956
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: