Healthcare Provider Details

I. General information

NPI: 1952786246
Provider Name (Legal Business Name): IRINA COSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 UNION COUNTY PKWY
CLARK NJ
07066-1917
US

IV. Provider business mailing address

31 UNION COUNTY PKWY
CLARK NJ
07066-1917
US

V. Phone/Fax

Practice location:
  • Phone: 908-531-5543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR12516100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00578500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: